This week I am very excited to be joined by my friend, Dr. Stephen Freiberg. Dr. Freiberg trained at Duke and Johns Hopkins and is now a cardio thoracic anesthesiologist in the Orlando area. Dr. Freiberg is here to discuss 10 key points to optimize and make good decisions while you’re transitioning clinically from residency to attendinghood.
The 10 key points that Stephen and I discuss are…
- Establish Clinical Excellence: The first step actually starts well before starting your first job. It starts by maximizing your training
- Trust Your Training
- Be Flexible
- Be Polite
- Be Punctual
- Be collaborative and empowering
- Be A “Yes” Physician
- Look to add value outside of clinical anesthesia
- Know Your Limits and the limits of the system
- Bring Solutions
I’m talking to Dr. Stephen Freiburg, and I’m really excited for this episode. It’s going to be a little bit different as you know, I am not a doctor. I saw, I stay far, far away from the clinical stuff. This week is a little different because I’m talking to Dr. Freiberg about his professional and clinical transition from residency to fellowship and fellowship to attending hood. And I’m going to let him unpack some of the steps decisions, some of the pearls that he’s picked up along the way and talk about how should a physician make smooth clinical transitions between jobs as you move towards an attending role as an anesthesiologist.
So hope you enjoyed today’s episode as always. Thanks for tuning in
Hello and welcome to episode 54 of the anesthesia success podcast. I’m very pleased to be joined this evening by my friend, Dr. Stephen Freiburg, Dr. Freiberg is a cardiothoracic anesthesiologist currently and attending in the Orlando area. He trained at Duke and Johns Hopkins. If you recognize his voice, you might’ve heard him on the [inaudible] podcast with our friend, Dr. Jedd Walpole, and he’s here today to just share a few pearls about how to optimize and make good decisions while you’re transitioning clinically from residency to attending hood. Dr. Freiburg, thanks for being with us.
Dr. Stephen Freiberg(01:37):
Justin, thanks so much for having me really excited, really a big fan of the show. And I wanted to reach out mostly because I heard Dr. Jimmy Turner do an episode where he talked about the successful transition to attending could really from a financial standpoint. And there’s no doubt that he is the expert in that realm.
Dr. Stephen Freiberg(01:57):
I’m a big fan of Dr. Turner as well. What I thought about and what I thought I could help bring as a reasonably new attending. I’m a couple of years in practice, and I don’t think I’ve made anyone too angry too far. I’d like to hope and think that I’m on a successful track is what I guess you could also argue as the first key to the financial standpoint. And certainly this is the anesthesia success podcast. The success standpoint is you, you gotta do well when you first, when you get that first job. And I guess this applies even to this is coming up on July 1st. It’s the same with new interns, new residents, and certainly new attendings. You, what is the first key to success and financial security is making sure your income is stable. And I think I have hopefully a little insight to help a new issue or a new attending or resident make that first transition smooth and really get hit the ground running. Yeah, I’m really excited to talk about that this evening and shout out to our friend, Dr. Jimmy Turner, thanks for introducing us. The physician philosopher a of the show as well.
And also, I’m glad you brought that up. Congratulations to all the new interns and the new CA ones who are now doing anesthesia for the first time. If you’re out there listening to this podcast, tell your friends about it because there’s a whole new,
Dr. Stephen Freiberg(03:11):
New crop of doctors. Now that could be
In what we have to say here today. So I’ve got this 10 point bulleted list here in front of me, Dr. Freiberger too. You were kind enough to send me, I just want to work our way through it. So why don’t you tell me number one, keys to a smooth clinical transition,
Dr. Stephen Freiberg(03:29):
An anesthesiologist. Absolutely. And you reminded me how awesome it was to become a CA one. Again, this is specific tendency, just so I can focus in on this a little bit, because at least for me personally, intern year was filled with things that I knew I didn’t want to do. And not to say that there’s not some value in the year end, you learn a lot, but to finally get to do anesthesia, just my whole life got better, my whole outlook improved. So the ones who made it and those folks that are going into anesthesia in your intern year while it gets better.
Yeah. I distinctly remember that transition for my wife. She had just moved to Philadelphia from Portland and that first year living in like a strange city for the first time and the, just the crush of intern year was so challenging. And it was, it was you know, our relationship was, we were sorting things out we’re in the same city for the first time. And it was just, I think about intern year. And I think that’s a very dark time. And then she came out into CA one and it was like this just, you know, she was so relieved and hasn’t looked back. So
Dr. Stephen Freiberg(04:34):
Yeah, engineer’s top. And then I think it corresponds with a lot of life transitions for a lot of people that tend to get clustered all at the same time. You know, folks, graduate med school, a lot of folks like to get married or finalized relationships in some way, all the while you’re moving to a new place, you might be purchasing a new home or renting a new home. There’s so many changes that happen at once. Not to mention you are now a real live doctor. So as much as we just stick, stick in there, hang tough, you’re going to do great. And it does get better.
Dr. Stephen Freiberg(05:06):
So, you know, I’m an anesthesiologist, I’m definitely obsessive, probably a little bit compulsive. I love making lists. And one of my favorite movies is actually high fidelity, which has recently been done as a show on Hulu, which I can’t say I’ve seen. So if anyone likes it, let me know. But I recently read the book as well. And it was kind of weird cause it’s one of those times where I had seen the movie before I read the book. And so the voices of the movie were already in the book, but anyhow, the movie is about this rather compulsive list-maker, he’s very into music and he always makes top five lists so I can relate intensely. So I did in fact, make this top 10 list for making a successful transition to clinical practice,
Perfect, which we are going to post in the show notes, by the way. So anesthesia success.com/ 54. You can find a copy of this list if you want to have it for a keepsake. Absolutely. So 0.1
Dr. Stephen Freiberg(05:59):
I actually say probably starts will definitely start even before you start as an attending or I suppose even an intern as a resident is to establish clinical excellence. And that really starts in training. And what I mean by that is I do think it’s the responsibility of the resident and of the learner to maximize your training. Yes, you hopefully have great attendings who are there, great cases, great people to learn from, but you have to learn as much as you can and look for opportunities to learn whenever you can, if you identify your weaknesses, work on them. If you figure out, Hey, you know, I’m really not doing so great on this page rotation. Or I finished my pizza rotation. I think I could use some work. That’s what you should focus on. I would argue that if you’re planning on doing a fellowship or a subspecialty of some sort spend time in areas, other than those, if you’re going to do, for example, pediatric anesthesia as your fellowship spend extra time in cardiac or regional or OB, whatever it is cause that’s the time to really hone those skills when you’re going to get an additional year in peeds, for example.
Dr. Stephen Freiberg(07:09):
So I really tried to do that and I think it helped maximize my education. And ultimately I ended up in a position where yes, I’m a cardiothoracic anesthesiologist, but I do a little bit of everything and I do nerve blocks. I do nerve catheters. I take care of healthy peeds and I think had I not maximized my education the best I could. I may have limited myself in the job opportunities available to me.
As you knew that you were going to do cardiac, did you make any decisions intentionally? Like what, what was the thing that you did in advance of the fellowship to say, Oh, this might be my last shot to do OB or to do PE
Dr. Stephen Freiberg(07:43):
I had quite literally did exactly that. At least the way the residency was structured at Hopkins, your CA three year is pretty open to make the selections of the rotations that you’d like. So I did additional time in thoracic. I did additional time in major vascular paeds, et cetera, because I knew, and at that point, I think I’m trying to recall the timeline. I want to say by end of CA two year, you actually even know where you’ve matched and where you’re going. So that was pretty much locked in. And so I was able to really sort of maximize what I wanted to focus on otherwise during my CA three year. And the other big thing is that, you know, let’s be honest, residency can be a grind and some days it’s easy to phone it in, you know, you put the tube in, you turn on the CBO and, you know, go on the internet.
Dr. Stephen Freiberg(08:30):
Not that anyone’s ever done that before or read the newest article, whatever it is, but you know, I really just try and push myself on days that I feel like I was wanting to phone it in, find something to work on, find something to perfect. How smooth can you get your wake up to be? How perfect can the hemodynamics be for your case or think about what is my attending really an expert in is this person, the absolute world expert in neuroanesthesia or whatever it is, ask them about. Neuroanesthesia really take the opportunity to push yourself because I would argue what matters more than where you go to train. It’s how you maximize that training. The best anesthesiologist is going to be the one who puts in the best effort. It doesn’t matter whether you go to the quote unquote best school. So I really think that you take the opportunity to maximize your time as a resident or even as a fellow, that sort of mindset should continue. That’s the first step in being a successful attending. Yeah. That makes a lot of sense. Yeah.
Let’s talk about number two. Trust your training.
Dr. Stephen Freiberg(09:32):
Absolutely. So it is terrifying to roll in your first day, second day, whatever it is, maybe your new job has a pretty lengthy orientation process. I know some places you get paired on with another attending for anywhere up to a week or two, not even because they don’t trust you or that you don’t know what to do, but there’s always a lot of systems to learn a new medical record, learn the surgeon, et cetera. My orientation was about three hours. I was paired with the anesthesiologist. He made sure my Pyxis access worked and he said, okay, you’re going to go take over this other room, which was a very, very sick, complicated case where I didn’t even know, you know, where all the drugs and the tubes were yet. But the fact of the matter is you have to believe in yourself, especially if you’ve taken the time to maximize that training, you know what to do, and it’s not an arrogance. It’s not an overconfidence, but you know what to do and you deserve to be in the position you’re in.
I know something I’ve talked about a little bit with Dr. Wolpow is just the idea of imposter syndrome. And I know that’s something he’s talked about a bit and with some of the content he has done over at [inaudible], and this is like exactly where it kicks in. You know, you’re looking around the corner, where’s the attending, it’s getting dicey. And then you’re like, Oh man, that’s me. So how did you deal with that?
Dr. Stephen Freiberg(10:53):
It’s tough. And we’ll touch on this a little bit in some of the other points, but the fact of the matter is for the most part, there’s always help available with some scary exceptions, but there’s always help available. And I would argue not unlike in a residency program, if you’re hired that group has now invested in you, at least to an extent they want you to succeed. And probably, and even more, I guess, a cynical way of looking at it. They don’t want any malpractice or lawsuit or bad outcome to fall upon the group. And if that’s contingent upon someone coming to help you, they’re going to do it. So that’s one thing to keep in mind. But again, there’s definitely that bit of imposter syndrome and it’s exactly what you said. It was like, Oh, I, where is the attending? Then it’s like, Oh, that’s me.
Dr. Stephen Freiberg(11:41):
Now you take a deep breath, say I’ve done this before, or I’ve done something exactly like it. And you put one foot in front of the other. And I think that, you know, similarly, as I said, you trust your training. You have confidence, but also have humility. And I think one of the things that rubs people the wrong way very quickly, and you’ll see it sometimes when folks transitioning from another job or from residency to fellowship, or if they’ve transitioned amongst institutions, especially ones with very famous names, don’t name drop. It just drives people crazy. If you say, Oh, this is the way I used to do it at man’s best hospital or whatever it is, you know, it will get under people’s skin so quickly just if they’re doing it a different way. And especially if it’s a safe anesthetic say, great, never done that way. Show me how you do it. Or even the more subtle way can just be something as simple as you know, I’ve never done it that way. Can I show you what I like to do? I think it’s a little less grading than when people start name-dropping. So I keep that in mind.
What about during my time in Boston? Is that acceptable?
Dr. Stephen Freiberg(12:50):
Well, I think better. I do think it’s better than a, any of those given hospitals. I think it might smooth over a little bit more. And then again, in conjunction with not trusting your training and being confident, also remember that a simple, straightforward, and safe anesthetic will gain you more traction than coming in. And you know, suddenly trying out new things. It’s not unlike, you know, when you take the oral boards, they’re asking you to do what’s safe and they will throw out options. That is going to be weird. And if you start talking about an anesthetic that you don’t know how to do, they’re going to nail you for it because they can tell you’re giving something that you’ve read in a book or in theory. And that’s okay. Like you don’t need to do some weird esoteric anesthetic because someone else does it. If you know, this is the way I can do it safely, there’s time to address to a surgeon’s preferences and things like that. And flexibility is an important part, but safety comes first.
Yeah, that makes a lot of sense. So you talked about flexibility as number three, be flexible. Things will change.
Dr. Stephen Freiberg(14:00):
Exactly. So I guess that transitions well into 0.3, you’ve got to be flexible. Your assignments will change. The surgeon will change. Who’s doing the case for change their plan. And again, as long as it’s safe for the patient’s care, try and adapt because I think it goes such a long way to be someone that’s adaptable and flexible. You know, if you get a big change or a schedule, change a simple, I got it. No problem probably doesn’t seem like much and to be truthful, it probably won’t garner much attention, but will we’ll gain a lot of negative attention is if someone gives you a change of some sort and you’re inflexible and you whine about it and you stomp your feet or cop an attitude that will garner attention. And that’s not the sort of attention you want in your first job.
No kidding. Can you remember a time when you came into a case you were prepping for a case and the surgeon was like, you know, what, can we maybe consider doing something a little differently? And it was a surgeon’s preference that you wanted to try to sort of straddle the line between accommodating a physician and advocating for patient safety. And you had to sort of like,
Dr. Stephen Freiberg(15:08):
Sure, I’m sure there’s time. That’s more times that I can even come to think of. And again, a lot of it will come. And I think I’ll mention a little bit about communication and expectation setting and even just how you frame things. I, you know, I might be jumping the gun on my list a little bit, but you know, the classic example you always hear about is NPO violations that the patient aid or whatever it is, and the surgeons say, well, we got to go. Now, one of the ways I’ll phrase things to surgeons that I think maintains an element of flexibility and a can do attitude, but also patient safety is I don’t say, and I’ve seen colleagues do this, Oh, the patient aid cases canceled. I will say to the surgeon, look, the patient ate two hours ago. If you think this is critical life threatening, we’re going to do it. Otherwise I will do the case for you in six hours. And I think just that simple rephrasing shows, the more willingness to help out then just being like, Oh, they were done. And I think that can go along.
Yeah. And I think that’s a nice segue into number four. A lot of I’m noticing a lot of these are universal truths be polite,
Dr. Stephen Freiberg(16:19):
But you know, I guess you’d be surprised or not surprised how quickly it seems. These universal truths are forgotten and that’s to be polite. I really can’t overemphasize that. And more importantly, it’s be polite to everyone. It’s to the nurses, to the texts, to the ancillary staff. You can’t imagine what it does for your reputation. And the fact of the matter is people talk and people listen and it matters. And as much as you might not think about the person who mops the floor, what their opinion is going to have an impact on that travels around and it helps work can potentially hurt build your reputation. And their reputation is really all you’ve got, especially when you’re first starting out. And I’ve listened pretty recently to a podcast where, you know, they talk about a lot of times you’d like to advocate that, Oh, I don’t care what people think of me.
Dr. Stephen Freiberg(17:11):
And I think there’s value in that. But at the same time, it matters a lot. When people think of you from the way you treat others and from sort of your moral fiber, so to speak. So again, to be a doctor who shows up with a smile and says, please says, thank you. Who, when you show up in pack, you actually helped put the monitors on the patient as opposed to just dropping and turning on your heels. People notice, and it matters. So again, just to be polite and what I’ve found in my comparative length of life, most of the time, it’s easier to be nice then to be a jerk. There’s more energy to be mean.
Well, then it probably says something about the kind of person you are too.
Dr. Stephen Freiberg(17:55):
Well, when can I leave?
I’ll tell you I’m a lot more likely to let somebody, like, if they say, you know, I just gotta like be honest and be myself. Like if that person who needs to just say, what they’re going to say is coming from a place of like, yeah, I’m a respecter of all human persons, both high and low and does treat everyone with that, like fundamental dignity. That’s going to give you credibility when you have a tough conversation, or when you say something that was taken the wrong way, or you have that, you know, you just have that relational capital with people and they know, you know what, this is somebody who cares about people. And maybe he in the heat of the moment when there were like 16 physicians in this room trying to handle this case, it went awry. Like he said something or whatever, that, that he, that he regretted. And you can, you can move on from a place of that common understanding.
Dr. Stephen Freiberg(18:44):
Exactly. And, you know, remember a lot of the folks at any given institution have been there a lot longer than you have, and you might not think it matters, but again, this one scrub tech or this person mopping the floors or whatever it might be might have known the surgeon you’re working with for the past 20 years. And in some strange ways, they might trust that person more than they trust you. And that’s okay. They have more relationship with them, but all the more reason you don’t even want them banned talking, you, especially if you’ve given them reason to bad talk you. So, you know, right. As we kind of get to the midpoint of this list, one of the more senior partners when I was first starting said to me, he said, look, man, being flexible, being easy to work with and being polite will take you farther in your career. Really more so than the speed with which you can place a central line or your ability to do some regional, you know, so obscure regional block is really just the way you interact with people. And I think you can’t undervalue that.
Yeah, that reminds me of a story. There was a, a guy like an older person in this company who would hire people. And he had this like local joint that he would always take him for lunch for the interview. And he was friends with everyone there. And he knew that they knew every time he brought someone in on an interview that it was a setup and that they were to essentially like get his order wrong,
Dr. Stephen Freiberg(20:09):
Stress it, and see if he
Treated the waitress, treated the cook and the manager with the dignity deserved by his fellow man, or if he like flew off the handle and it was this guy’s, you know, hypothesis that, that told him everything he needed to know about the character of the person he was, he was about to hire. So I think, I think that’s brilliant.
Dr. Stephen Freiberg(20:31):
I kind of like the strategy. I’ll be honest. I think a lot of those little techniques are employed and even more formal interview situations. People just want to see, you know, how you interact and what sort of moral fiber you have. So, and you know, at least if you’re a jerk, you get a free meal out of it, I guess.
Sorry, number five. This is this one’s near and dear to my heart be punctual.
Dr. Stephen Freiberg(20:53):
Oh my goodness. I, you know, I was routinely amazed as I progressed through my training adults, adult learners, but they are adults some with, well, I’ll take a step back. Some of the children that adds an extra layer to the complexity of punctuality sometimes, but ultimately these are all adults. Some of them were older than me have had other careers and they were late. They would just show up late all the time. And we’re not talking like, Oh two minutes out of the door, like 25 minutes late. And it’s like, what are you doing on the first day of residency? And look, things happen. I get it. But most of the time, a lot of the time you can make steps to limit the likelihood with which that can happen. So let me tell you, it was on my second day at this job, I was, I was stand by miscommunicated into showing up late.
Dr. Stephen Freiberg(21:48):
And actually, frankly, it was even, it wasn’t even technically late. It was later than is the typical expectation of the preop staff with which they see the attending anesthesiologist. And that news spread so quickly that I got a call from the division chief shortly followed by the chief of the group, inquiring about why I was late on my second day. It’s not a good feeling and it’s not a good way to start. And I felt like I was doing pretty aggressive damage control from that, you know, minor error for a, I’d say a good month. So learn from inferior people like myself and just show up on time, get up a little early, enjoy your coffee if you’re there too early, just be on time. Really speaks volumes. And look to the fact of the matter is in many institutions, the culture is a lot of other physicians are later than we are. And for whatever reason, that’s given more leeway, but a certainly as a new physician and as an anesthesiologist, you will not sell if you’re setting yourself up well to try and, you know, test that dynamic.
I’m curious how, how those two phone conversations went. And if if you’re a miscommunication was looked on graciously,
Dr. Stephen Freiberg(23:09):
I don’t think so. He was on top of that. I wasn’t in a position to sort of throw the miscommunicate or under the bus, nor did I feel like it was really their fault. And I said to the person, I said, I, I said, I’m not asking you to understand, you know, how I was late. You know, I was, this is what time I was in the preop area. And I was into the, or, you know, five minutes early. And he said, well, that’s not how we do things here. You need to be here by this time. I said, okay, you know, so sorry, what happened again? And he said to me, he goes, look, you said, he was look, you’re new here. You don’t want to make waves. And I was just like, not trying to make waves, man. Didn’t know what time the culture was to arrive.
Dr. Stephen Freiberg(23:48):
So, you know, if you can get that information early, that’s probably helpful too. But you know, that comes down to, you know, if you make mistakes, you own it. I didn’t, I didn’t get long into Oh, but so, and so told me this. It was like, sorry, didn’t know what happen again. And just kinda kept moving on from there. Makes sense. Number six, be collaborative and empowering. Absolutely. So I kind of mentioned a little bit, even when we talked about sometimes having to compromise with surgeons and the example about NPO violations. What’s NBO by the way, sorry, nothing by mouth. As you might know, Justin is you for, well, this is actually changing with enhanced recovery after surgery protocols with there are typically some sort of restrictions on how close to eating and drinking before you have your surgery. Got it completely appropriate. And actually I learned embarrassingly recently, it stands for hope when I’m saying this wrong it’s nil per us, which I think is Latin or some smart person language for nothing by got it.
Dr. Stephen Freiberg(24:55):
But again, so much, it’s just how you phrase things, but being collaborative and empowering a thing is especially Jermaine in anesthesia care team models and a supervisory situation, whether it’s with nurse anesthetists or residents or anesthesia assistants, I think you might have a little bit more leeway to be prescriptive, especially when working with residents, they are training and learning after all. But I think we’ve been value is how you’re looked at as an educator and as an attending to empower your learner or empower your coworker or anesthesia care team member. Again, remember, you’ll be working with folks who might one be more experienced technically than you are in terms of how long they’ve been working in a given field or at minimum. And they may have been at that institution longer. So again, it also has to do with flexibility. If someone in your anesthesia care team model has a particular way of delivering an anesthetic and it’s safe, it might not be worthwhile to really, you know, create a Hill to die on, to change that anesthetic technique.
Dr. Stephen Freiberg(26:00):
In fact, you might even learn something. And what I would say is that if there’s a situation, which you think is pretty significant to hammer home, or if you think it dictates a change in the anesthetic plan, engage the members of your team. And I’ll often say something to the effect of, you know, I think this patient would really do great with X, Y, or Z with a TIVA anesthetic or an extra antiemetic. What do you think, how do you like to achieve these goals? How do you think we should address his critical aortic stenosis? And I think guiding those conversations can one often teach you a thing or two and again, empower the members of your team. And I think when a person feels empowered and not micromanaged really helps the way you’re looked at and really helps the way you’re able to work in your team. Again, whether it’s other surgeons, anesthesia professionals, it all just goes to teamwork and really go a long way. And I think great strides have been made to move away from the sort of a solo superhero cowboy physician and recognition to how important it is for medical teams. And that certainly is no exception in anesthesia.
Yeah, that makes a lot of sense. I was listening to a podcast, one of the podcasts that I like called the moment by Brian Koppelman. I don’t know if anybody else out there listens to it, but he did a recent interview with a guy named Jocko Willink. Who’s a pretty famous like a management consultant now, but he’s a Navy seal and a, a guy who’s basically an expert in leadership leadership techniques. And he was telling this story in this podcast, I’ll link it in
Dr. Stephen Freiberg(27:35):
Leading from a place of humility with questions and involving others creates buy-in that increases cohesiveness that will show you your blind spots. You might just find a response that you don’t expect when you ask a question, like, what do you guys think? Like, well, because, you know, I could easily see somebody making an observation in some instance where it’s like, wow, I maybe I missed that detail or that was something I didn’t consider. And it may be a, you know, a salient fact to the way you’re going to administer care. So leading from a place of engagement and asking questions and getting buy in just has so many benefits. And that was something that he saw, you know, in war that the example he was using, I was like platoon leader. We’ve got to like, you know, take this Hill guys, what do you think is the best way to do this? And obviously in the context of asking others to put their lives on the line that buy in is very important. But I think, you know, in a similar kind of way, creating a team atmosphere and a common goal, and having everyone participate in pulling the same direction in the, or is also very important.
Dr. Stephen Freiberg(28:44):
Absolutely. And that reminds me, there was an interview I’d heard with Peter Pronovost, who was at Johns Hopkins for a long time, was world renowned for the work he’s done with patient safety. And he also told a story, I think again, military related. And it just has to do with empowering the members of your team, that if you ask the individual who’s mopping the floors of an aircraft carrier, and you say, what is your job? They’re going to tell you, I help launch planes from the aircraft carrier safely. They’re not going to say I’m off the floors. That’s only a small part of the greater goal. And certainly almost universally when you get into problematic or heated or controversial situations in medicine, especially with the medical team with rare exception, everyone wants what’s best for the patient. And I think that’s the common goal. And as long as you can empower people to feel that they are purposefully involved in that goal, you’re gonna have a better working environment. Makes a lot of sense.
Number seven BA yes. Physician, what does that mean?
Dr. Stephen Freiberg(29:47):
So, you know, I think class, we has heard of it’s the thought is, you know, be a yes man, but you know, keep her she and lady physicians and lady bosses, all that great stuff. And I really am all for it. So I think yes, physician is probably the better way to describe it. And again, shout out to Dr. Jimmy Turner. He says he has a hell yes policy, meaning that if something doesn’t make him say an enthusiastic, how yes, he doesn’t do it. And I get that policy and I love it. What, at the beginning it might be prudent to bend that just a little bit and be willing to take on responsibility or to say yes to things that maybe doesn’t give you quite the hell yes. Feeling or even more. So look for the opportunities that do make you say, hell yes.
Dr. Stephen Freiberg(30:37):
Again, if you’re approached to lead a committee or, you know, take on a certain case or a leadership role, either seize that opportunity and say, yes, I’m here for it. Or at least maybe provide an alternative. If they say, you know, we want you to lead our committee on obstetric, anesthesia safety, and you can’t stand obstetric, anesthesia James, or you wouldn’t be invited into that committee. Those things tend to not go on notice, but you might say, you know what? I really appreciate you being, you know, you asking me that, but my real passion is vascular anesthesia. I would really love to join this committee. And I think again, that shows your willingness to be involved and that you’re here for the team and to make your group or your practice or your residency program better. And so I think if you again, say yes to a variety of opportunities, some may surprise you in that they might turn out to be a very wise decisions that you’d come to love, or certainly at a minimum.
Dr. Stephen Freiberg(31:35):
And again, shows that you’re to torture the catchphrases, that you’re probably the go getter that you more than likely advertise yourself to be when he interviewed with the group. Right? So it’s not a good impression if you say, you know what I’m here, I’m a leader, I’m a go getter, et cetera. Those are all things we say in an interview. And hopefully we mean them. And if you’re new to a group and they say for lack of a better word, all right, prove it. And you go, ah, no, not interested again, you know, these things are remembered. So again, if something, you know, literally gives you chills or corrupts your, you know, your inner wellbeing, I’m not saying to go for it, but you know, give a little bit of wiggle room to the hell yes. Policy and look for those opportunities. And certainly from a critical standpoint, when it comes to caseload and getting cases done, especially at the beginning, you know, I’m all for work, life balance.
Dr. Stephen Freiberg(32:30):
It’s important. We should prioritize our wellbeing. But again, you’re here to show that part of the reason you’re brought on to this group or this team is you’re here to do the work. So at least for the beginning, first few handful of times, Hey, are you willing to stay late? Can you do this extra case? The answer should be an unhesitatingly. Yes. And I think in an amount of time, if you find that you’re really sort of being abused or being asked to stay late too frequently, it actually might tell you a lot about the group in that might not be the right place for you. But overall, I think you should show that willingness to stay late and work hard, et cetera. And it really does speak volumes.
That makes a lot of sense. Were there any opportunities for you maybe early on, or maybe even in your residency or fellowship days where you implemented this policy and perhaps you had to like reconsider your knee jerk reaction, say, you know what I’m gonna, I’m gonna do, I’m going to do exactly what you just described or maybe that’s something that you learned along the way.
Dr. Stephen Freiberg(33:28):
Well, I’m going to be very, very personal with it is that, and I’m not telling this story with which to brag in any way. It’s just the truth experience. I was humbled and honored to be chief resident at Johns Hopkins. And it was a great opportunity. I learned a lot, but it’s a lot of work and it’s a lot of responsibility and it’s a lot of dealing with interpersonal challenges, as I believe your wife will find out soon enough. And it was a wonderful opportunity, but I couldn’t wait to be done with it when the time finally came. And right around that time was coming up. I got an invitation from Duke university where I was about to start my fellowship. Is that, would you be willing to be our chief fellow? And you know, again, I said to my wife, you know, she’s, she goes, she goes, there is no way you’re doing this after, you know, the amount of times she’d watched me make schedules.
Dr. Stephen Freiberg(34:19):
And I quite literally said, you know, this is exactly what I told this program that has been kind and generous or stupid enough to match me that I am a leader. I’m here to go ahead and that’s exempt. I said, they’re basically saying before I’d even started the program, can you be a leader? How am I going to say no? And I think that helped establish, hopefully the reputation I said for myself as I started the fellowship there. And hopefully they didn’t come to regret that decision too horribly after a year’s time. And ultimately I didn’t either is the truth of it. So
Yeah. And that one does hit close to home because you know, anybody out there who has a significant other who’s married, like it’s, you’re not just committing for you. And I similarly with Sarah, you know, we’re talking about her being a chief this year and she’s like, she’s like, you know, what do you think? And I was like, well, I, you know, I think it sounds like an amazing thing and I want you to absolutely like go for it, but it w we reflected like, this is, it’s not just her, it’s kind of our family and it’s me. And it’s our son who are all in, in her corner and supporting her. But also we’re all kind of contributing to that. We have, we have skin in the game and it’s, you know, that’s something that while I agree with everything you said, I, I’m also cognizant of the fact that there’s competing priorities in life and your job is what it is. And it’s very important to take excellent care of patients and to be a leader. And you’ve got to hold that intention with Erin for your loved ones and doing the other things that are very important to, you know, like you said, your mental health and other things. So I think that probably takes a while to just kind of learn,
Dr. Stephen Freiberg(36:00):
Right. And really one can’t trivialize in any sort of way, the experience of a physician’s family, especially through training or even after training increase, you know, it’s a, it’s really a journey taken by all parties involved and it can be incredibly challenging and burdensome. And I think communication and expectation setting is really clearly digressing here, but is really the key to success in that regard. And even to say to your partner, look, you know, these first six months, I’d rather be home with you, I’d rather be home with the kids, but if you can offer me a little bit of grace for a couple of late nights that I might be home for, not might not be home for dinner, might not be able to put little Jimmy to bed or whatever it is. You know, I think as long as they understand that this is hopefully a temporary component of your journey and that you’re trying to build success for your family as a unit, hopefully you’re involved with a partner who, you know, understand and you shared that sort of goal and value together and can, you know, offer a little bit of grace for a couple a missed appointments or whatever it might be.
Dr. Stephen Freiberg(37:05):
But, you know, I can say as a husband and father, I try not to make it too much babble.
Yeah. I mean, a hundred percent. We get to have a whole other episode about that. And maybe we will one day, maybe we could do the 2.0 okay. Number eight, look, to add value outside of clinical anesthesia.
Dr. Stephen Freiberg(37:26):
Absolutely. So it’s expected that you will be a great clinical anesthesiologist as simply as they wouldn’t hire you if they didn’t think so. No one hires someone into a group thing like, eh, they should be able to get the job done. It’s just not what it is. So how else will you add value to your group or your practice? And again, this is an opportunity where I think you can be a little bit more selective is what is it that makes you say, hell yes, and go for it. Are you passionate or skilled in a quality or administration or research or education? That’s something that, again, I think find what’s important to you, but sees and look for those opportunities, even if perhaps are not offered to you, look for opportunities to create them. The example I’ll give is I had a very difficult and challenging case with a poor outcome.
Dr. Stephen Freiberg(38:20):
And I said to a trusted partner, I said, look, you know, what sort of form do we have to discuss these cases? So we can all learn for them. He’s like, Oh, you know, we really don’t. I said, no. And he goes, no, it would be awesome to have something like that. And from that, I basically built up, you know, the, I know that the connotation has kind of changed over time, but you know, what is historically known as an M M and M conference morbidity mortality conference? I think now it’s a little bit more PC to call it a systems based practice or a systems review, which I think has some value in that the analyzing a medical error, isn’t about finding out what one person did wrong. It’s what are all the pieces that went wrong to allow an hour to allow a poor outcome in order to improve upon it.
Dr. Stephen Freiberg(39:04):
But that to me was something that I’ve always been passionate about and was a perfect opportunity to seize upon. And it’s been very well received by the group as a whole. And people have said like, Oh, we’ve, we’ve needed this for so long. So we look for those opportunities. Whatever’s passionate and bring those to your group in addition to your ability as being a great anesthesiologist and especially in the challenging political climate we have, when it comes to anesthesia and anesthesia care, you know, how do you bring value outside of the operating room is really important.
Yeah. That’s a whole another episode. We’re getting all these episode ideas, right.
Dr. Stephen Freiberg(39:40):
You’re going to be writing this down.
Yeah. Okay. We’ll keep it moving. Number nine. Know your limits and the limits of the system.
Dr. Stephen Freiberg(39:48):
Correct. And I hit on this pretty early, but it’s always okay to ask for help. And I guarantee, again, anyone in your group would rather help you avoid a poor patient outcome than not lend a helping hand. So class example for this. So my second day I was late or more or less late my third day as my kind of standard preop evaluation goes. I said, you know, have you ever had any problems with anesthesia in the past? No, no problems. I just have this. And the patient handed me a difficult airway letter. This is my Owen. And on top of that, it was a rather old letter. So it wasn’t especially helpful where it said, this is how my airway was successfully secured. It basically said this patient was really hard to intubate. Good luck. Wow. And so I said to one of the more senior dogs who we have, what’s called a charge role.
Dr. Stephen Freiberg(40:39):
They’re the guy that kind of runs the board. And then in many ways as there to also help lend a helping hand if needed in addition to their own rooms. And I said, look, man, I don’t know what I’m getting into here. This lady just handed me a difficult airway letter. Do you mind, you know, being an extra set of hands when I induce and there was no hesitation, there was no what’s wrong with you. There was no, you know, you sure you can’t handle this by yourself. It was with, you know, without a blink of an eye and sure thing, call me when you’re ready. And that was that. And so I think that was probably looked at more favorably. I would hope then have I gotten myself into trouble and was on a third or fourth intubation attempt who was calling overhead for all, you know, for surgical airway.
Dr. Stephen Freiberg(41:21):
So again, you know, trust your training, but know your limits. And it’s okay to ask for help. Similarly, while I feel quite comfortable taking care of healthy peeds, we’re big hospital, we have a lot of sick kids and I was scheduled in the endoscopy area and they said, okay, you know, the next case we’re bringing down is a two year old from the PICU. And I said this is not within my comfort zone. And again, I called to one of our strategy docs and said, look, this I’m not comfortable with this case. I’m happy to, you know, again about how you’re phrasing. I’m not trying to just sit this case out. I said, you know, can I swap with one of the P’s cardiac guys and one of the PA’s guys and no one batted night because no one wants bad patient outcome. Everyone wants to take best care of the patient.
Dr. Stephen Freiberg(42:08):
So trust your training, but know your limits. And when it comes to limits, it’s not only your individual limits, it’s important to know the limits of the system. And when you come to a new place, in addition to not name dropping and not being rude to people who have to work and fit within the resources and confines of the system that you’re in. So a classic example that I think of is we did a lot of thoracic epidurals, actually, both places I trained in. So just a nonclinical person, epidural, you know, you’ve probably heard when women have babies, when they go into labor, kind of the same idea, but we actually place it higher up in the back. And it’s useful for thoracic surgery or certain abdominal procedures. But for they, a program with thoracic epidurals to succeed requires a lot of pieces to be in place.
Dr. Stephen Freiberg(42:59):
You need nurses who are well educated about thoracic epidurals and how to use the pumps or how to troubleshoot them, or what to look out for, for a problem. You need a team of either physicians or advanced healthcare practitioners who can round on those epidurals and make sure they’re working appropriately. All these pieces need to be in place. And at the group that I arrived in, they didn’t really have those pieces. And maybe even said that they’ve struggled in the past with a successful thoracic epidural program because of some of these pieces. So it would not do me any good to necessarily drop and say, well, I think the best thing for this patient is a thoracic epidural. If there’s not sort of the support and resources for that to be a useful solution. So it’s great to bring ideas and bring change. And Hey, maybe that’s something you can take on as a new physician to build upon that program.
Dr. Stephen Freiberg(43:50):
If it’s something you’re passionate about, but you have to know what works for your system. And again, all kind of blends together, flexibility, adaptability, and a go getting attitude is certainly the way that you can bring change, even within limits of the system. I’m curious with that tough airway, how’d it go? Oh, it was actually really easy and it’s not a, it’s not a bragging point. I suspect that it was an older letter and airway equipment has evolved substantially in that time with video laryngoscopy and whatnot. So in fact, the, she had the difficult airway bracelet that was put on her because she had the letter and the senior physician who very pleasantly came right in the, as it was ready and induced and we easily secured the airway. He goes, Oh, cut that thing off. And so luckily it went okay, that’s funny.
Dr. Stephen Freiberg(44:41):
Great. I think my number 10, and I think a lot of what I’ve said today, and hopefully I didn’t sound too redundant kind of points in this direction is bring solutions. Don’t bring problems. You are undoubtedly going to find problems in any new job. You find that problems exist everywhere, and it might be the same problems of somewhere else you’ve made. It might be different problems and that’s fine to identify and address them. But again, it will take you so much further to say, Hey, this is something I noticed I’m not comfortable with it. I think it’s problematic. This is what I think we can do about it. How can we do this? Who do I need to talk to as opposed to just coming in with complaints saying, Oh, well, you know, your preop workflow really sucks. You know, chances are, someone’s already commented upon that. If there aren’t already programs in place to fix them, that’s where you jump in and again, show your value and bring a solution to the people who are in charge.
It makes a lot of sense. So I want to close Dr. Freiberg with a question that I ask most of my physician guests. I don’t know that I prepared you for this in advance. I’m curious to hear what you have to say. I’d love to hear a brief anecdote from your career as a physician, about a time when you were, you know, obviously you’ve worked really hard, you’ve trained a lot. You’re, you’re an expert in a lot of different things to be an attending anesthesiologist. Tell me about a time when, whether it was a tough case or collaboration with some of your physician colleagues a time when there was this moment of like actualization of realization of like, I, I kind of, I’ve made it, we made it like all the hard work has paid off. I’ve achieved the goal, I’ve attained the skills. And I, I’m a, I’m a competent physician in ways that as like an ms too, I could’ve only dreamed, right.
Dr. Stephen Freiberg(46:35):
I still get hit with those moments every now and then. And it’s funny because, you know, I, I’m lucky to work with a group that I really like all the, all the folks that I work with and we text and we ask each other clinical questions and there’s folks that like one, one day I literally will text them. I’ll, I’ll just shoot us actually. Like I’m the best anesthesiologist. And you know, and the following day I’ll be like, dude, I’m going to get fired. Like, you know, I get not because anything bad thankfully happened, but just you know, I keep a critical eye on myself and my own performance. But if I had to pick a case, I guess it was a case that had been kind of punted along the way, I think largely cause no one wanted to deal with it.
Dr. Stephen Freiberg(47:15):
Combination of both from a surgical standpoint and an anesthesia standpoint. So much to the effect that it somehow got scheduled on a weekend, which is not a good time for things to necessarily happen, but it was a with a interior media Steinle mass. And so for any anesthesia folks listening, those are potential disasters to put a patient to sleep depending on how symptomatic they are, because we are experts at airway management, I would say pretty much from, you know, chin to sternum, pretty much anything in there. We can work with anything beyond that. There’s not a whole lot we can fix. And I wasn’t convinced that even my surgical colleagues quite understood what we were potentially getting ourselves into. And I guess a really bold physician may have just said like, Oh no way. But again, in sort of phrasing things and tuning things, I said to the surgeon and I said, look, I’m going to do this case either you put in what we call, you know, awake groin lines so that a patient can go into ECMO or emergency if they need to, or I’m going to.
Dr. Stephen Freiberg(48:29):
And he was like, yeah, yeah, whatever you need to do. And kind of went about his day. And I think that’s a pretty bold induction plan when you probably sounds good and oral boards and all sorts of things like that. But it’s a lot to tell a patient to go through. And I coach the patient and explain what I was concerned about and how this is different from how we normally do things and all the kind of plans I put in place. But, you know, I made sure the profusionist was in the room. I told the nurses what I wanted. And I really think that in that moment I took control of the situation informed the patient, did a very sort of complicated induction that was executed better than I could’ve dreamed. You know, and I hopefully that was a mix of skill and lock as I think a lot of great things are. And I think it was that moment, quite specifically, that I inspired the texts on my friends, where I said, you know, I’m the best anesthesiologist in the world that I got him, you know, through this induction safely. So that was a good moment. I’m sure there’s been more of them and more that are maybe a little bit more touchy feely about times that I really know that I made a patient feel good and all that good stuff, but that one stands out for me anyway.
Awesome. Well, thank you very much for sharing that story and thank you for joining us today on the anesthesia success podcast.
Dr. Stephen Freiberg(49:44):
It was a pleasure, Justin, thank you so much for having me. I look forward to maybe podcasting more on some of these ideas we came up with and again best of luck to all the new attendings, all the new private practice docs, residents, interns, you’re going to do great. Take my tips, believe in yourself, work hard. And I still think medicine’s the best field of there is. So you’re on the right path.
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