10 Adaptability

You will recognize the people and events that have been most impactful for your career after you have matured as a physician and perhaps served as a mentor. As I look back now, I find myself remembering a few people for their especially positive impact on my life that I could not have envisioned earlier in my career. Some of these people and experiences presented challenges at the time, but each provided an opportunity to grow professionally and become more resilient.

I had just completed my orientation at Oregon Health Sciences University (OHSU). Every first-year anesthesiology resident had been assigned to their first rotation with the faculty member who would serve as their preceptor for the first month of training. On the first day of the rotation, I was walking with another first-year resident to the Portland Veterans Administration (VA) Hospital, which was a short walk from the main teaching hospital at OHSU.

As we were walking, we met two senior residents who had just been relieved after being on call the previous night. They looked tired but were relaxed and happy to be off duty. It would be several weeks before I would be taking call. I needed to become competent at intubating patients as well as learn other basic resuscitation skills prior to receiving my first call assignment. One of the senior residents asked who we had been assigned to work with for our first month at the VA. I responded, “Dr. Walker.” They were both silent. After a pause, the more senior resident said, “So you are the chosen one!” He chuckled and said, “Don’t worry, he is not as bad as everyone says.” My ears perked up, but they did not provide any further information, leaving me curious and a bit more anxious.

Once I arrived at the VA and found the operating rooms, I paged Dr. Walker, as we had been instructed to do at orientation. I had tried to call him the night before but was unable to reach him by pager or phone, and the fact that we had not already connected made me a bit nervous. Dr. Walker appeared immediately. “Why did you not call me last night!” he demanded with some obvious irritation. I hesitated and then responded, “I am sorry. I paged you, and I also tried to call you by phone several times last night.” He did not respond. After an awkward period of silence, he gave me a brief tour of the operating rooms and introduced me to the charge nurse as well as a surgeon using their formal titles. They were equally unimpressed, meeting me as simply another new resident in the operating room.

I had learned that Dr. Walker had a history of military service. He carried himself like someone who had lived a life of discipline with leadership responsibilities. The nurses in the operating room theatre were reverent and perhaps a bit intimidated when he entered the room. When we arrived at the operating room where we would be caring for patients that day, Dr. Walker emphatically stated he would show me how to set up the anesthesia cart with medications the “right way” and make sure the anesthesia machine and ventilator were “good to go.” I started to take notes until he stated I needed to commit this ritual to memory and no notes should be taken. I still made mental notes, hoping I could write everything down when he left the room. He never left the room that first day.

Our first case was an elderly veteran who had benign prostatic hypertrophy (BPH). He was very gracious when I met him saying “Whatever you need to do, Doc!” Dr. Walker asked me how I thought we should manage the anesthetic. Before I could answer, he said, “We will do a spinal anesthetic.” I mentioned I had never done a spinal anesthetic and was about to ask him if we should give the patient the option to have either a general anesthetic or sedation prior to performing the spinal, but he preemptively dismissed my concerns stating “These veterans are tough, and he will not need sedatives. I will talk you through your first spinal block.”

My first day working with Dr. Walker did not go well. I largely attributed my struggles to a lack of experience in performing procedures and to anxiety. He focused on things that did not seem to be important at the time, such as organizing my instruments and medications in a certain way. The second day, I performed every procedure while providing a spoken narrative for Dr. Walker to describe my next moves. I felt this exercise would provide him some reassurance as well as an opportunity to provide guidance. He was silent. I was gratified that every block that second day worked! At the end of the day, I expected some positive feedback. Dr. Walker was obviously not impressed. In fact, he chided me for a few lapses in my sterile technique, which I now realize is very important and should have been pointed out. After Dr. Walker left the room that evening, an older circulating nurse in the operating room approached me to say, “It is not you, he treats all the new residents like this.” This kind outreach was exactly what I needed to put the day’s events into perspective.

Each night, I carefully reviewed the cases and procedures I would be performing the next day. Anesthesiology, surgery, internal medicine, and pharmacology textbooks were my exclusive night-time and weekend companions during my first rotation. I committed to improving each day, as all new residents should. I was also motivated to improve out of fear of being reprimanded by Dr. Walker. In retrospect, I probably learned more about being a physician in this first month of residency training than during my four years of medical school.

As my training progressed, I had several additional rotations at the Portland VA Hospital, giving me more opportunities to work with Dr. Walker. Over the course of my residency as we spent more time together, he softened his approach to my instruction. I also became more comfortable asking questions without fear of being judged too harshly. As I observed his practice, I began to appreciate his kindness and commitment to his patients. My most lasting memory of Dr. Walker is the reverence he had for each veteran under his care. Prior to administering induction medications to a veteran, he would often say, “Do not worry, my friend. I am going to take good care of you, and I will be here when you wake up. You deserve my best.” I later learned that Dr. Walker had early in his career committed to working at a VA Hospital, foregoing a promising research career.

It was fate that the last day of my residency was at the Portland VA Hospital working with Dr. Walker. We were caring for a veteran with severe coronary artery disease and poor ventricular function following several myocardial infarctions. He was scheduled for coronary artery revascularization utilizing cardiopulmonary bypass, which would be a long and complicated procedure lasting several hours. I was given almost complete autonomy to manage the case with minimal intervention by Dr. Walker. In fact, we came off cardiopulmonary bypass without Dr. Walker coming into the room despite the patient requiring significant hemodynamic support. I suspect he was standing outside the operating room monitoring events and was prepared to intervene if necessary. Dr. Walker had given me instructions to call him only if I needed assistance. I transported my patient to the cardiac intensive care unit after surgery was completed. I stayed in the unit for over an hour to make sure the patient remained stable, give report, and assist the critical care team with adjusting his cardiac medications and ventilator settings.

When I returned to the operating room, every member of the nursing and surgical staff had left except Dr. Walker. He had a big smile on his face. He walked up to me and placed his hand on my shoulder. He then softly said, “Tom, you have been one of my favorite residents. If I ever need to have surgery, I would love to have you take care of me. Let me know if you ever need anything.” He shook my hand and left the operating room. The nurses in the operating room had already cleared my workstation, and Dr. Walker had returned my unused cardiac medications. As I walked back to the main hospital for my final night on call, I fondly remembered my first day of residency as the “chosen one”, walking to the VA hospital to work with Dr. Walker.

Adaptability is the ability to adjust to changing conditions. A definition of resiliency is the capacity to endure, adapt, and recover from adversity. Your longevity and well-being in a chosen profession depends in large part on becoming resilient over the course of your training and career.

Figure 2. Reconciling expectations with reality

An important component of navigating adversity is understanding that your commitment to your chosen career path and accomplishing your goal is commensurate with the challenges you will face, and your professional expectations are realistic and achievable (Figure 1). A strong sense of self with the ability to understand who you are, and your values provides the foundation for weathering adversity. Through adversity, you learn to focus on your career objectives, relying on your core attributes and growing self-confidence. As you gain experience facing adversity, you become more self-assured in your ability to adapt to difficult people and challenging situations. Staying focused on your long-term goals helps you deal with change or disruption in your personal life and professional career. Part of becoming resilient is developing the self-awareness to use your support systems to help manage extreme or prolonged hardship.

Figure 2. Strategies for becoming resilient

You need strategies to deal with the inevitable adversities you will face during your career (Figure 2). Training programs and institutions are focusing more attention on raising awareness of the need for resiliency and promoting programs to assist individuals in adapting to change and becoming more resilient. Seminars and workshops focused on helping you to rely on your core attributes are a foundational goal of many of these sessions. Another primary aim of wellness programs in medical schools and postgraduate training programs is to increase students’ understanding of how to maintain mental well-being through self-care. Developing coping skills such as meditation and adopting a healthy lifestyle with good nutrition and physical activity are important. Institution-sponsored sessions are often conducted using small group formats to foster the development of peer relationships and support systems in the local community. Local support systems serve as readily available resources for comfort and counseling when confronting adversity. A survey of medical schools in the United States and Canada published in 2021 confirmed most schools had established wellness programs to address both preventative and reactive interventions to assist medical students in dealing with stress.

In another study published in 2019, a survey of anesthesiology residents and recent graduates revealed a surprisingly high incidence of burnout, distress, and depression throughout the continuum of training. This was a cross-sectional survey of U.S. anesthesiology residents to determine the prevalence of burnout, distress, and depression using the Maslach Burnout Inventory, Physician Well-Being Index, and Harvard Depression Screening Scale. Longer work hours were associated with a higher risk of distress and depression, but not burnout. Regulatory agencies, such as the Accreditation Council for Graduate Medical Education (ACGME), and individual training programs survey residents on a regular basis to ensure institutional compliance with regulations that were established to moderate resident work hours. A positive finding of this study was that perceived institutional support, work-life balance, and strength of social support were associated with a lower risk of burnout, distress, and depression in residents. These findings confirm the merit of institution-based wellness programs.