EP38  – Conflict and Identity in the medical education process with Dr. Michael Miley

In every operating room, in every ward, in every clinic, and every team meeting, a silent battle brews. Conflict, negotiation, identity. Welcome to the Scalpel and Sword podcast, where I, Dr. Lee Sharma, physician and conflict analyst, Explore the hidden negotiations beyond modern medicine. Let's trade burnout for boundaries and learn the art of healing with precision and power.

Hello, my peaceful warriors. Welcome to the Scalpel and Sword podcast. I am your host, Dr. Lee Sharma, physician and conflict analyst. And I am so excited to have on the podcast today, Dr. Michael Miley. Dr. Miley is a graduate of Auburn University. He went to medical school at the Alabama College of Osteopathic Medicine, and he did his residency and chief resident year at HCA Florida Blake in Bradenton, Florida. He's board certified in internal medicine, and he's currently on faculty with the UAB Heersink School of Medicine in Montgomery at their regional campus in their internal medicine program. Dr. Miley, and of course I'm going to call you Michael because we have known each other. I was actually trying to do the math today on how long I've known you.

Let's see. I think I started taekwondo in 3rd grade. So I don't know how old you were, 8 or 9. Now I'm about to be 30 next month.

So at least 20 years, at least 20 years. So full disclosure, I have known Michael most of his life. He started taekwondo. So you probably started when Sam and Rachel were like 6, 5 or 6 is about right. And so we all trained together. Dr. Miley, I actually love saying that. Dr. Miley is a 4th degree black belt in taekwondo. He also was on our competition demo team, SNS, and he competed with both of my kids. I have really been excited to watch his journey and watch him as he has progressed through this process. So I am so happy you are here.

Thank you for having me. I'm excited to be here as well.

So one of the things we were talking about before we went on mic, Was that you really have had a process where you have medical student, resident, chief resident, and now you're an attending. When I say the words conflict in medicine, like when I use that phrase, what comes to mind for you?

I think that there's a lot of areas where conflict can happen, both in the team, but also between the team members and other staff members and communication issues. There's a lot of internal conflict also is a big part of the training that we go through. So there's a lot of different aspects, I think, that where conflict is involved.

Yeah. Do you remember the first time, either medical student, resident, whenever, do you remember the first time you actually witnessed something as a conflict situation and went, oh wow, I can't believe I just saw that, or I can't believe I was just part of that?

Yeah, I mean, I think in your probably third year where you're going through the different specialties, you know, every month is a brand new work environment and you see a lot of different personalities and different ways of interacting. And sometimes the surgical specialties are a little bit more rough around the edges and the working with the staff members. I've, and I've seen some temper tantrums from all different specialties and lashing out on the staff, lashing out on medical students. And it's kind of all attributed to just, this is the way we do things, which I think there's a big culture shift now for people that are in my generation where they're trying to flip the narrative on that. And it's not supposed to be in a work environment where that kind of behavior is tolerated from men.

I love that because one of the things that you really picked up on as a medical student was it existed. It's cultural and it's not appropriate. It's one of those things that the negative connotations are basically letting conflict have almost a free rein without actually having structures and processes to address it. And also the toxicity that that creates. If that's something you're seeing now, I agree with you 100%. The younger doctors who are coming into practice now have a much better understanding of the fact that not only is it not appropriate, to be in that kind of environment, it really contributes to so many negative aspects in healthcare.

And I think that also younger doctors these days are not putting up with being talked to that way, or, you know, the work environment. There's a much more emphasis on work-life balance and wellness as a whole. And yes, we are physicians and what we do is very important, but also having a life outside of medicine and valuing that, that this isn't all we do. And I think That's been a very big culture change that sometimes rubs people the wrong way as well, because back in their day they were working 120-hour work weeks and they think that 80 hours is not enough. And the things down the road that come from that as well, in terms of valuing your work-life balance and who you are as a person and not just working 24/7 in the hospital.

100%. I have watched younger physicians come up. And I think as you guys have been really centered on the idea that this is important in terms of having a work-life balance, being able to be a physician and not have that consume your identity. We love our job. We love our patients. We love what we do, but it is not the be-all end-all of who we are. Because I think my generation and the generation before mine especially really did embrace that as their identity.

Right.

And I think that's also why you see generations before me You know, you'll still see 70-year-olds going to clinic. They're still rounding. It's like, dude, when I'm 70, I'm going to be sitting on a beach someplace. Guarantee you that I will not be doing this. And I'm not saying all 70-year-olds. I mean, this is something that I think is different for different people, but that's why they still come in. It is so ingrained in who they are. They don't know who they'd be without the practice of medicine.

Right.

And I think that for people like you, that your generation and the younger physicians coming up understand That being a great doctor doesn't mean it's the only thing I do. You understand that there's other parts of you that come into that.

Definitely. And that's part of our training now is the wellness and valuing that life outside of medicine too, and pushing that in part early on in medical school training and balancing that. You know, burnout is a huge topic, which, you know, I don't even think that was a term back then. Now it's like kind of a big component in burnout training and trying to avoid burnout and Some of it is also systemic, just what we do. We have to work long hours and someone has to take care of people at night and emergencies happen. But a lot of it too is, I think, switching the onus to putting it from, if you're burnt out, it's a you problem, you're not resilient enough, versus looking at the system and how the system's not set up to be supportive of trainees in that environment and trying to figure out how we can fix that system rather than You need to sleep more, or you need to have this lecture on how to be more tough and deal with the system. How do we fix the system itself to prevent this from happening is kind of what we're going to now.

That's a huge insight. And I think that's really important that you bring that up because I definitely think, at least for a lot of people, especially in the pandemic, post-pandemic, I think that was a message that a lot of us got. Like, if you're not handling this well, you need to go get on a yoga mat. You need to do this. And it's like, well, maybe we shouldn't have you working 3 days back to back. Um, there's definitely an idea that the system plays a part in that. And we are part of that system, but recognizing that the system is inherent in this as well. One of the things that you just said that I love, I want to get into is you said you started getting an awareness and actually teaching about burnout and how to work with burnout, even when you were in medical school.

Yeah. I mean, we had whole classes, lectures on Being aware that, you know, this is a big issue. Unfortunately, there's a lot of suicide in the resident population and dealing with stress and how to cope with that. The work, long hours and the medical system of, you know, where you match, you might be far away from your family and kind of in a new environment, or maybe not in a specialty that you originally planned. And, you know, there's a lot of things that are out of your control. Yeah. And I think burnout happens when your expectations are not aligned with reality. And sometimes there's a lot of things that are outta your control as a trainee that you have to focus on. So they give us lectures on, you know, how to deal with stress and importance of sleep and the ability to kind of put things on the back burner if you need to kind of keep moving and focus on, you know, priorities.

Wow. So you got very concrete teaching. I mean, these are very specific things that you're being asked to do. And, you know, in terms of recognizing that burnout will exist, I think that's a big part of it is that, you know, I think they surveyed the medical student population and they said that 70% of medical students are already burned out. And of course I read that and went, only 70? I mean, I think it's higher than that, but things like getting sleep and managing cognitive overload, these are very concrete things that you can carry with you to deal with that burnout. Did you draw upon a lot of that when you were a resident also?

I don't think so. A lot of it I think is they're still learning how to best teach this and it comes across as, you know, pizza parties and mandatory wellness lecture versus just giving me that hour to go do something that I wanna do rather than have an hour lecture where you're telling me the benefits of yoga or tai chi or all that kind of mindfulness and groundedness. I would much rather just have that hour back to go and You know, catch up on whatever. But I do appreciate that we're putting a focus on it. But in residency, it's kind of, uh, you just gotta get through it type of mentality. But, you know, I was very lucky where I trained that they put a lot of emphasis on work-life balance and a system of residency that I didn't really think would exist in many places. I mean, we got 2 days off a week on pretty much all of our rotations except for like our general wards.

Yeah.

But even on nights or ICU, we managed to get 2 days off a week. And so it felt like you were kind of working like a regular 9 to 5 type job sometimes depending on your rotation. And that was a foreign system. I think that's probably one of the only residency programs in the country that operates like that. And I still got amazing training and saw all the things I need to see, but also was able to have a life outside the hospital and be well rested. So I enjoyed coming to work even as a resident.

Wow. That's huge. And I think there is a thought process, especially again, I'm going to get back to old people like me that said, unless you are working 100 hours a week, unless you are actually in the building, unless you're actually seeing patients and doing the thing that you're not learning. And it sounds like you were in a program that struck a really good balance between having you be interactive, having you be the caregiver, and yet giving you time off so that you could sleep. So you actually had time to digest and process what you were seeing.

Mm-hmm. And yeah, definitely.

That's very complementary to the learning process.

And I think it's very specialty specific. You know, in internal medicine, you learn a lot by reading and not always by doing like a surgical specialty. You can't really read your way through how to take out an appendix. So I see where the work hour restrictions can kind of, uh, you know, have some play of if you're not doing the surgery, it's hard to learn that. But for internal medicine, as long as you're reading and learning, You can pick up a lot of things without always seeing the physical patient. So there is a bit of a dynamic difference based on what specialty you're in. But, uh, I think that the programs had to get rid of a lot of fluff. You know, it's not just doing grunt work. Like a resident shouldn't be like drawing labs and pushing patients around, transporting to the hospital, you know, on your work hours. You should be seeing patients, reading, learning. And don't get me wrong, I had a very nice, you know, non-millennial program, but we worked very, very hard.

Yeah.

I was always at my patient caps in terms of the number of admissions I could do, and I got a really great training. So it was the expectation when you're here, you're here to learn. And so there wasn't a lot of fluff. And so everything from the teaching, the rounds, it was all to be as efficient as you can with the time that you're here. That way you can have that time off. I mean, we still work the same number of hours. It was just kind of spread out differently. But I think it's probably some specialties aren't amenable to that based on the exposure that you need in terms of, you know, you have to get this number of procedures under your belt and there's no other way to get that experience other than by doing it. But how do you balance the time in the hospital to make that as efficient as possible? And I think that's really where people are pushing now.

Yeah, that's a great insight too. It's this idea of just empty hours aren't necessarily empty hours, that we have to be efficient with how we're training our residents so that they can maintain that wellness. And that is going to be a valuable life skill for Do you find that, you know, sort of this practice of efficiency that you learned in residency, has that been serving you well also as an attending?

Yes and no. It's a very, you know, different, the way that the time works and being as an attending is the rounds, I'm waiting on them to do the notes and then sign the notes versus me kind of being, you know, more efficient as an intern and doing the work. You know, a lot of the quote unquote grunt work where you're doing the labs, the orders and the notes. A lot of times, you know, my, Role is kind of supervising. And so the time management has been a little bit different.

Mm-hmm.

But I still kind of work like a resident. I still get there very early. I see all the patients before rounds. We can table round to be much more efficient with our rounds and then allow them to have enough time to do their work. But I tell them all the time, like, there's no glory in being that person that's getting here at 4:00 AM because they're not efficient at writing their notes. And also having to stay until 8 or 9 o'clock to finish the notes. The one that should be bragging was like, hey, I've done done all my things and my notes are in, my orders are in, and you know, they're done by noon. And so then I can follow up on the patient stuff. And when it's time to sign out to the on-call team or the night team, you know, everything's tied up. There's no glory in being that person that's working, you know, so much. You wanna focus on the efficiency. So I try to get them more efficient, but for me as an attending learning a new hospital system and everything, I've been there for about 6 months now. So I have my kind of flow now, but I can only be as efficient as the team is. So my goal is to try to get them to That's good.

You're passing that skill onto a new group of learners.

That's really cool.

Yeah.

And you know, they have the different number of patients to see. And so it depends on what time of year it is. If you're in July with brand new interns that don't know their way around the hospital, the EMR, it's a lot different than working with an intern in March where they're getting ready to progress onto the PGY-2 and become a senior resident. And so they're much more efficient. And so the time of year and the team composition does change. Definitely matters a lot too.

Absolutely. It sounds like your program was really great in terms of how they helped you guys experience this learning curve. Did you have a program that had a lot of hierarchy? Was it a very hierarchical program in your opinion?

Yeah. I mean, the senior resident pretty much ran the team. So the intern, you know, we had about a 2-week orientation period where you only had like 1 or 2 patients. Sometimes, and then as the couple weeks of July 1st went on, then you kind of built your way up to 10 patients in a more controlled manner. That way you could focus on just learning the EMR or how we do things at our hospital and how rounds are gonna work. But with 1 or 2 patients where you, you can take all day writing your notes, you're still learning everything. And then we kind of build them up and then set them loose with 10 patients. But you're always, as an intern, supervised by a 2nd or a 3rd year resident in our program. The only time that you weren't doing that was when you're on a specialty elective where it's just kind of you and the Attending one-on-one, you know, there you have less patients, but whenever you're on the wards and ICU or on nights, you were never alone. And I think that allowed them and me to build a lot of autonomy because you kind of got to prove yourself and you got autonomy as it was earned and kind of as you were ready for it throughout the year to take on more and more ownership of coming up with a plan and running with it and things like that. So I think most programs probably have some type of orientation process. They don't just throw you clean into the deep end because you have to learn how the process works. Every hospital is different. Where I'm at now, we have a lot of international graduates and, you know, some of them are just learning how to live in the United States, much less the medical system too. And I even had a big transition, you know, just training in Florida and coming back to Alabama. It was like a whole new system and new way of doing things. So it's a big adjustment no matter where you are, and you have to acknowledge that.

Absolutely. And I really do think because the way you're describing how you trained, the fact that they progressed you into autonomy, the fact that they didn't just throw you in and say, okay, here's your 10 patients your first day, that they actually gave you a space to learn how to do all of these things. And then it's okay. Okay. Dr. Miley's ready. So we can go ahead and move him on to 5 patients. Okay. He's doing great. We'll move on to 10. They actually gave you a space to do that. I wonder by virtue of giving learners that space, if that decreased conflict in your program. I wonder if that made it easier for attendings to help them and made it easier for them to understand how the system worked because they had space to do it.

Yeah, I think it's definitely a challenge, but I think that's something that I'm really interested in studying is how we better assess autonomy and going back to like comparing it to a surgical specialty. It's very easy to assess whether or not you know the steps of the procedure. You learn it, you just open the skin and then you do the next step. And then they give you a few steps here and there, and then slowly it builds into this big person, you know, you can do the whole procedure now. But in internal medicine, we don't really have that kind of system because we're caring for patients with multiple diseases. You might be really good at AFib, but you might know nothing about diverticulitis.

I see.

But the patient has all of this going on at one time. It's hard to assess autonomy, you know, individual based on like a individual disease pattern and how do we progress that? Because in internal medicine right now, it's mainly you do your 365 days as an intern and then now you're a senior resident. You're running the team, you're making all the decisions. And how do we better assess that throughout the year rather than just being on a kind of a time base? You know, we have milestones you're supposed to hit and everything, but some of them are very objective. And so that's something that I'm interested in. That's from an academic standpoint and just kind of how we better assess, you know, autonomy and grade that and allow them progression based on kind of the skills they prove by this time in the year. You should be able to do, you know, this skill or this discharge paperwork or the med rec or whatever the skill is, you know, based on the number of experience, but also too, you do different rotations throughout the year. Some people, even if it is December, they might've done a lot of electives and never done ICU yet. until later on in the year. So it's hard to put everybody on a standardized path in internal medicine.

I really agree with you on that. I think even in surgical specialties, I think that assessment can be challenging, even though you may be able to say, okay, well, this person can do a C-section in 20 minutes. That's great. That still may not be a true assessment of where their clinical maturity is. And I remember the first time my husband and I had this conversation and I was like, you know, when I think about medical students and residents, I think about data, information, knowledge, and wisdom. And he looked at me and was like, what? Okay. Let me put this in another way. I said data is the medical student goes and brings me an x-ray. That's a piece of data. Information is he puts the x-ray up and goes, look, there's a pneumonia. Knowledge is he looks at the x-ray and says, okay, this patient has pneumonia. I would like to give them this antibiotic. Wisdom is I have this patient who's been in the hospital for 3 days who now has a pneumonia, but also has esophageal cancer. I wonder if he's chronically aspirating. And all of a sudden this picture has developed from just this X-ray into now we have a story. And when you have somebody who can take a piece of data and then build the story, at that point, I'm sort of saying, okay, you've got some clinical maturity there. And I think when you start thinking about those kinds of scenarios, because I think one of the things that happens a lot of times in medicine, especially in education, I would love to know what you think about this, that we expect people to progress in a linear fashion through those 4 steps. And they're not. And so if you are teaching that person and they're not progressing through the steps the way you think they should, or maybe the way you did and you think everybody else should be that, you're automatically going to be in a conflict situation with that learner because they are not meeting your expectations in the way that you think they should.

And that's something that for me, I, as a resident, it was a lot more challenging because you're not so far removed from the intern when you first become a second-year resident where You know, you're running the team and you're kind of like, well, why can't you just, you know, just write the notes? Like just put the orders in. You know, they don't even know what the CBC entails, much less how to order it. And so like the cognitive overload is so high and you forget, like they don't know how to do really anything in the hospital, you know, much less, you know, me as an attending, I'm like, okay, I remember I've had my years of dealing with interns in the beginning of the year where you just know that you have to hold their hand through a lot of things. And so that definitely is frustrating.

Yeah.

When you think that someone should know something and they don't, was it me not asking the question the right way, or do they know something else about the topic? I, I ask a lot of why, why, what's your reasoning behind this? Not just, this is the plan we want to do. I ask a lot of why questions. That opens up a lot of, you know, avenues to, you know, if there's an error in the thinking. Sometimes a broken clock is right twice a day, you know, but sometimes you have to figure out, do they really know clear indications for why they're doing this? Or did somebody, a lot of times the intern is just regurgitating the plan that the senior resident told them before rounds. And so, mm-hmm, I really want to assess, do you understand why you're doing this? What can happen if you do this or that? And asking a lot of why questions I think is really important. So now as an attending, I kind of know really what I need to identify in order to assess, you know, do they really know what's going on or are they just kind of giving me superficial things and I think that has helped a lot because as a resident, it was very frustrating when I was working with medical students and interns because you expect them to know something if you know it. But then as an attending, you're kind of like, not everybody's on the same level as you and has different levels of experience and different levels of training. And so trying to figure out where in that cognitive path is the issue, is it a knowledge issue or, you know, did they not ask the right question or are they just not putting the pattern together? So sometimes rephrasing the topic has been helpful of like, okay, forget about this patient, but if I say I have this and this disease, you know, symptoms, then what kind of pattern is it? And then you, when you break it away from the patient, because in internal medicine we're responsible for the whole patient. And so I think it gets very overwhelming, especially, you know, I take care of ICU patients and they have a lot going on and it can be broken if you break it down into, okay, this is anemia. What do I do for anemia? Then it's not this big scary diagnosis. Okay, this is pneumonia. What do I do for pneumonia? And you just list and keep going down all the assessments and then it builds into this big plan. And so sometimes they might know 5 or 6 things about one plan, but not 2 or 3 about another plan. And so when you break it down individually, then it comes into a whole of its parts. And I mean, that's been a helpful strategy for me and them to teach them how to systematically, you know, approach a patient. And that way everybody's on the same page and communication-wise.

I love this so much. I want to break this down because I think this is beautiful what you just said, that when you're working in this process with your learners, that you are using a lot of why questions. And I think anytime you're in that space of using why, you're exhibiting curiosity. You're not making assumptions about why they may not know or what they don't know. You're actually wanting to know, okay, where are you? Where's your headspace? What is your thought process? And curiosity to me is one of the greatest ways to defuse conflict. Because one of the greatest sources to conflict in medicine, and I think this is true everywhere, but especially in the academic setting, is assumption. People assume. You're assuming, okay, well, my intern doesn't know this. Did he not learn that? Did he not read it? Did he not pre-run on the patient? You're making an assumption. And that assumption is so dangerous because it may literally be, no, no, no, he did all that stuff, but this is a flaw in his rationale that I need to find. So the why questions become very powerful. Was that something that, as you went through this process, you know, intern, resident, chief, attending, is that something that you saw was lacking or was that something that was modeled for you and now you're using it?

Well, I think it was more modeled. We had a lot of attendings that, I mean, they wanted us to have autonomy, but they always wanted to make sure that we were being safe. And that's the balance in academic medicine is how much do I hold their hand versus how much do I let them try to figure it out without affecting patient care. Uh, but we always had to justify every decision we made. You had to sell your diagnosis to the attending. And so it was just kind of the model that was our program and to make sure that we really knew the why behind what we're doing. Because, you know, there's usually like 3 or 4 antibiotics that will cover any infection and they would be like, well, why would you do this one over that one? And then we'd talk about, you know, the cost disparity or, you know, hospital formulary or what's covered by their insurance.

Yeah.

Things like that. And then you kind of learn the reasoning pathway. And so, yeah, I think that helps diffuse a lot because I don't wanna make assumptions. Say, oh, you didn't examine this patient. Or ask them, what did their legs look like to you? Like, did they look fluid overloaded? And then they say, oh, you know, no, their legs had no edema. And I said, well, I saw them and they were the Pillsbury Doughboy over here. And so when you press on it, and so an error in your exam skills and stuff, we'll talk about that. And also too, it comes back to efficiency is that I don't wanna waste their time teaching them something that they already know. So I quickly can kind of see where they're at in their state of training and kind of tailor the education. 'Cause a second-year resident, third-year resident who's, you know, been here for a while, they don't wanna sit on rounds and listen to me talk about how LASIK works. And they wanted to get to the next level for their own education. And so balancing that, because the interns need a lot of the basics, medical students, a lot of the basics, it's their first time. hospital, but a senior resident who, you know, is functioning more in an autonomous, independent role, they need to be learning the kind of next level questions and how the management goes for that. And so that's been challenging is how to balance the teaching, cuz I love the basics and can talk about that all day long, but I don't wanna bore the people that already know that. But also balancing that has been a challenge too.

Oh my gosh. I love how you're approaching this. This is really cool. I love how you are finding your way of doing this. I mean, you've seen some good stuff modeled, but you are building sort of your path and persona as an attending, which I think is really cool. I'm gonna bet that when you are a chief resident, because I think one of the things about chiefing is that you really are the bridge between the trainers and the faculty, you know, a lot of that's gonna go through you. I bet you got pretty good. At resolving conflicts between residents?

Oh yeah. I think that's probably the most conflict year that I had was cuz I was a 3rd year chief resident. So, you know, I was still a resident and so I had to do all my regular residency things as a 3rd year, but also we had 3 chief residents. So I had 2 co-chiefs and we kind of split up the duties and everything. But we were a pretty big program. We had 22 categoricals in each class prelims, and we had 80-something residents.

Oh.

That we were in charge of. Yeah, it was a pretty big program. And so had a lot of conflict. We had to hold a lot of people accountable and getting really good at that. But also too, balancing that as like, you know, I'm not above them and I'm still the same, you know, in the hierarchy. Yes, I'm a chief resident, but also I'm a third year as well. So balancing that with your friends was a challenge, but also they wanted us to be in that position. So I felt that they trusted us to hold them accountable and So yeah, we had to have a lot of tough conversations, but we had that kind of backing and the mandate from them to, you know, to have us in that position and to hold them accountable. So a lot of conflict, scheduling, people calling out sick, and then to find out that they're partying and not really sick, showing up late and, or trying to kind of dodge work and things like that. And just having conversations with them, but having a good relationship and a trust from them that, you know, I'm not attacking you as a person, but this is what of a, it's a behavior and not, you know, a trait. And so balancing that was fun, but I'm glad I'm not a chief resident anymore.

Yeah.

I wanna talk about that because that's wisdom and that's something that a lot of people who are, because I think this happens a lot in medicine, people end up being sort of accidental leaders. You know, people who are in leadership at their hospitals, you know, if they're department heads, if whatever they're Kind of find themselves doing in those roles. Number one, I think it is good that you knew that with this big program that people put you in that position. So that was a leadership position that was agreed upon by everybody else. I think that's huge in your ability of approaching conflict. But one of the things that you just said that is so cool that I think a lot of people in leadership don't get is that if you're having to work with somebody who maybe is throwing things in the operating room. Or talking ugly to staff or not showing up where they're supposed to be, that you're talking about the behavior, not the individual. Because so often when people are having to be in leadership and having to work with somebody in this conflict, that they are looking at the person. So-and-so did X. And so that's their mentality when they're approaching it. And it sounds like your mentality, which I think is great, is this is a behavior. This is not the individual. So this is not a personal attack. This is me talking about what the expectations are of the program for your fellow residents. You don't want to dump on them. You want to pull your weight as well. And so you're encouraging them to step into that role in such a way that they don't feel like they're personally attacked. Was that also something that was modeled for you, or did you see that in action where you learned to do that?

No, I think that's just kind of the strategy that I found was most successful, you know, because we had to have a lot of hard conversations With people that were not performing at the level they wanted to, not holding to standards. We had to kind of create a whole standard cuz like I said, we had a very collegial program from like the attendings into the residents. We were a very close-knit program.

Mm-hmm.

And people really tried to take advantage of that sometimes that, you know, we got a lot of time off and tried to kind of abuse the system a little bit. And so you had to kind of hold them accountable and we had a lot of issues. And so that was probably the strategy that I developed. I don't think anybody really modeled it for me, but It was just about to kind of get them to understand, cuz not every residency program has the bad eggs in every program of people that, you know, like to show up late. They're habitual late people. We had one person that their car was just always broken down and you wanna give them the benefit of the doubt, but also this guy, he probably would've just built a whole new car with all the different parts that had broken down, you know, throughout residency.

Yeah.

You know, it was just like, you just know that they're not telling the truth and you have to kind of hold them accountable and. Have those conversations. And so we kind of picked and choose. I was one of the chiefs that people liked to come to with their issues to try to fix it. So I had to be a mediator between a lot of people. It all comes down to just kind of communication and this is affecting other people. We had a lot of issues with our transitional years, but those are people that are going into dermatology or radiology, but they have to do their year of internal medicine. A lot of people pick our program cuz we live at the beach and it's nice weather and it's a cushy program, fellowship program. They kind of take advantage of it. As an intern, if you call out sick, the work falls on your senior. When you're a junior resident, you don't really feel the impact that it's having until you become a senior resident. And then if your co-senior calls out, now suddenly you're going from seeing 10 patients to 20 patients because your co-senior calls out. You know, that's a big strain on you that you weren't really ready for that day. And so then you start realizing, okay, maybe I shouldn't be calling out as much. And getting them to understand it's not just calling out sick, you're putting work on somebody else and we have to rearrange coverage and things like that. Also, it's your job and— Professionalism, you know, you have to tell, even when you're out on residency, you can't just not show up for work. You have to call out sick and find coverage and kind of preparing them for real life too. And so making it not just like, I'm getting onto you, but like, these are things that, you know, we can't allow to continue on, you know, because it's affecting the overall workflow and the patient care.

So it's like one of the things that you did really well as a chief is framing these conversations. As part of a larger, I don't wanna say system, but part of a larger process. It's like, I know you wanna call out today. I know you wanna stay home. I know you wanna go to the beach. It's a beautiful day outside. I would love that too. However, these are the expectations that we have, and when you don't, you know, rise to meet them, unfortunately there are other people and patients who are going to pay the price for that. So framing that, I think in that way, this is part of a larger thing. This is not just about you. I think that's really important and being able to carry that through and hopefully they'll carry that through as they progress in their careers. You also said that you ended up running a lot of mediations as a 2L.

Yes.

Because, you know, this, it's a hierarchy. We had multiple seniors on a team or something. We kind of did round robin for the admissions, but maybe somebody would be like, oh, like, I'll just take the next one. Can you do this? I mean, people try to kind of punt the work and Mm-hmm. You know, make it seem like they're doing, you know, some people wanna take the first admission, some people don't wanna take the first one. You kind of know in our program who's gonna kind of dodge the work. And, you know, there are some people that kept getting put with the same people over and over and just kind of butted heads and they weren't gonna get along. And so you had to kind of sit them both down and be like, look, you don't have to be best friends, but you have to be professional and have to be able to work together for the patient care's sake. And that's how I always tie it back to, this is how it's affecting your job. I get that you're not gonna be best friends with this person, but you have to communicate with them. You have to work with them because we have 10 admissions that we have to go see. So somebody's gotta see it and all of us have to pitch in and do what's required of us. Yeah, there's a lot of kind of butting heads. Like I said, we were a big program, so sometimes you were lucky where you didn't have to work with the person that you didn't. I wasn't best friends with everybody outside the hospital, but we were always able to work together. Some people, they don't have that skill to be able to just kind of put personal feelings aside. And so we were kind of able to spread some things out to where maybe you're not working as much with that person, but sometimes the schedule falls where it is and that's just what you have to deal with.

And that's important too, right? When you're walking into a mediation, when you have people, especially in medicine, it's like, I would love to have you with people that you're best friends with all the time. That is not the nature of a schedule. You're going to be with people that you don't like, but this is the higher calling. This is what you're actually here for. And, you know, there's a name for that in conflict resolution. It's called being the agent of reality. So when you walk in there and you're telling, okay guys, I mean, I know you don't like each other, but this is how it's going to get done. And this is how we care for the patients. A lot of times just being that person and making that statement can be really powerful because all of a sudden it's like, okay, dang, we can't just sit here and fight about this. We really have to get up and get this done. And I wonder how many times you had to go past that one thing. Like when you're mediating a conflict and you've got these 2 residents and they don't like each other, they're fighting about workload and you're sitting down with them and saying, I get it, but this is our expectation of you within this professional role. And we want you to rise to meet it. I get it. You don't like that person. I think you can get past that if you can be professional about it. How often did you ever have to go past that in terms of resolving those conflicts?

I don't think we ever had to go past that. So. Yeah, it's been working. I didn't know there was a term for it, but I guess so.

There really is. And I can't tell you, like, even mediating disputes with attendings that are just, I hate him, I hate him. And you're sitting there at a table with them. I cannot tell you how many times being that person has been, all right guys, I know you can't, but let me tell you who's suffering and actually list out the patients are suffering, your coworkers are suffering, the nurses who work with you can't stand to be around you because they're tired of you fighting like little kids. This is not how professionals act. And just having somebody, and I will say this, I think being the doctor saying that, I think you being a chief resident saying that, you know, you have done what they are doing and that carries some weight, especially I think in medicine. And we should be the kind of people that will listen to people in conflict resolution or mediation, no matter what they do, even if that's what their primary focus is. But those of us in medicine who can do both.

Yeah.

who can work in mediation space and who are also medical professionals, people do tend to listen to us a little bit more because they see us as, okay, well, this guy really gets what I do. He's done what I do. And so he gets it. He's not just talking to me. This is not just somebody who's coming in and sitting down with us. He's lived my life and he understands it. I always think that carries a lot of weight.

Yeah, definitely. And I think, you know, too, just putting a label on it, putting it out there and being like, this is an issue instead of just Kind of letting it fester and everybody knows these 2 don't like each other and it's kind of, it becomes the talk of the program. And when you sit down and just be like, look, like you, this is an issue and kind of, I think just talking about it, I think helps with everything.

I would 100% agree with that because I think so much of what happens in medicine, especially with this kind of conflict, is that people know it's there and they ignore it. Mm-hmm. It's like, you know, we all know it exists. We all know they don't like each other, but nobody actually wants to have that conversation about it. We're a very conflict avoidant culture in medicine. We're not good at it. We've never been taught to be good at it. So people like, you know, you've gotten good at it because you had to, because you were in this leadership role and you had to get good at it. You didn't have a choice. I've talked to so many chief medical officers, people who have been thrust into that role, and that's what their interest in conflict resolution came from because they had to learn it in the role you're in, just like you did.

Right.

And so now you're seeing people who are getting better and better at it. So I was laughing a little bit when you were talking about talking to the medical students, the interns, the upper levels that you talk to them differently. You're trying to gear that conversation. You have very good things that you wanna teach the interns, very basic things, but you wanna keep the conversation at a good level. So you're sort of challenging your second years and your third years. And you know what that sounded like to me? That sounds like teaching a class with white and black belts.

Yeah, definitely. When they're all in the same room and you're like, Just, you're not on the same level. You have to kind of keep everybody engaged, you know, definitely. That's—

And it's hard. It's hard, right? Because you want to challenge everybody in the room. You want to challenge the front row and the back row. You want to have everybody feeling like they walked out of that class, that they accomplished something, but that's really hard to do. And I think I would say coming up, teaching people, having that interaction where you had to learn how to steer that. knowledge base to so many people in a different place in the same room. I think that starts very early if you've studied any kind of martial arts, cuz you carry that with you. So I love it that you're doing that now.

Yeah, I'm still, you know, trying to figure out how best to do it, but with my own system of how to do things. But at least I acknowledge that that's something that you have to kind of keep them engaged. It's not just kind of me giving my same old talking points. I try to keep it relevant and When in doubt, we'll throw in some board questions, question banks. And so the 2nd and 3rd years are, their boards are in 6 months, so they're really trying to study right now. So I'm fresh off my board, so I have a lot of board fodder that I just kind of regurgitate, the buzzwords and things like that. And so I can at least share that with them cuz I'm, so, uh, you know, partners who are more seasoned, you know, attending, so, uh, have a little bit of a different perspective too from that. Yeah.

Oh my gosh. And see, I know they value that because you actually are taking that into consideration. The fact that people are at different levels, cuz I don't think that always happens in medical education. I think, like you said, you do have people who it's like, I just have an audience. I am the attending and you will listen to what I'm going to say. And it might be what my research is on, it might be my most recent publication. You know, whatever I feel like talking to you about is what I'm gonna talk to you about.

Mm-hmm.

And you have people who definitely get left behind in that process and they start to lose a little bit of interest. I think it's amazing what you are doing and what you have done. So if you could pass on one piece of advice to, let's say you've got some upcoming chief residents at HCA, you know, they're coming up and they're like, hey Michael, I just got chief resident. You're like, oh man, that's great.

You know?

And they ask you, it's like, what would you tell me? The one piece of advice I should have to have a Successful year as a chief, what do I need to know?

That's tough. I'd say it's all temporary. It'll be over soon. No, I mean, I think that having your relationships with your co-residents, it depends on if you're a 3rd-year chief or a 4th-year chief. Some programs do a 4th-year chief where you were at another program and you just come in and you're just kind of the chief resident over everybody and you may not have the relationships. And so that's a different dynamic than being third-year chief where you still are a resident. And so, you know, being a peer, but also having those extra responsibilities, I think it all comes down to the relationships and the communication. I think we were very open with our communication. And again, coming back to the why, you know, why is the schedule like this? Or why am I always on this team? Or I have to work the holiday and explaining the rationale.

Yeah.

Our chief residents don't get to control the schedule. And so they just kind of get handed, here's your rotation schedule and here's when you're on nights and here's when you don't have the weekend. We try to be very fair and upfront. Everybody can see everyone's schedules. You know, even as a chief resident, one of my co-chiefs worked on Christmas. We had the ability to really switch up the schedule. I could give myself whatever day off I wanted and kind of abuse that. And we made a conscious decision that people were gonna be all eyes on you. I think maybe that's probably the best advice is that people are gonna look at, they're gonna comb through your schedule with a fine-tooth comb and say, well, why did you give yourself this rotation here? You know, people are always gonna be watching you no matter what, and kind of with a different lens.

Mm-hmm.

You have some, you know, abilities to make things a little bit better for you. I got to pick the order of rotations and when I wanted to do what and kind of who I got to work with and assigning the teams and things like that. So, uh, people are always watching, but I think if you communicate, I think that you'll solve a lot of issues just by being, you know, transparent with kind of everything going on.

You have done so much. Your journey is amazing. I think you've developed, you already had wisdom and then you walked through this process and I think it's just really grown and exploded in terms of the things that you've done and how you've walked through this. I'm really blown away, Michael, by how you have matured in all of this. And it's joy. It's really awesome to see your progress and to see where you are. I remember way back when you spent, I think a couple of times, because Shosh and I were talking about this because you followed him on the wards.

Yeah. He was the first person that I shadowed because, you know, originally I wanted to be a pharmacist, and then you set me up to shadow the pharmacist and then I was like, oh, this is not really what I had envisioned. And then you were like, you're gonna be a doctor, you just don't know it yet. And you said that to me. And then I started shadowing, shadowing. I was like, oh, this is really what I thought it was gonna be like. And so that was my foray into medicine right there. So yeah, he, I watched, he did like a thoracentesis. He was just like, boom, boom. You know, we saw a lot. It was just, you know, really eye-opening for me and kind of confirming that's what I wanted to do. do, and then the rest is kind of history. You know, my parents didn't go to medical school, so you guys were very big cheerleaders and supporters and mentors through all of it. So I definitely would not have been where I am without your and Josh's guidance for sure.

I think you would be there anyway. I'm glad we got to be a part of your journey. I think you would be here right now shining and helping so many people, but it's been lovely to have seen you kind of jump into that and then be able to follow all the great things that you've done. And I really look forward to seeing where your career takes you. I think you're going to pursue in academics, and I love how you talk about that you have an interest in seeing how people progress in their clinical maturity. That's something that really means a lot to you. And as you develop more insight into that, I would love to have you back on the podcast.

Thank you.

Because I think that would be a fabulous topic for us. We could literally spend a whole show. Just talking about clinical maturity and the acquisition of clinical skills. I think that would be amazing cuz I think that process is important, but I also think in terms of seeing conflict on the wards and how people learn and the different ways they acquire that, I think that's just gonna be our next episode. So you definitely have to come back on the show.

Yeah, definitely. It's not a well-studied field by any means. And so that's kind of why it's more interesting to me cuz it's just kind of like people just kind of do whatever they want and find their way and I would try to make a more systematic approach to how we train.

I love that. Michael, thank you for being on this show. This has been fantastic.

Thank you. I really enjoyed it as well.

So for all of our peaceful warriors who have joined us on The Scalpel and Sword, thank you for being here. And until next time, be at peace.

Every episode is an invitation. To speak, to negotiate, to choose. I'm Dr. Lee Sharma. Join the dialogue by subscribing to Scalpel and Sword. Until next time, peaceful warriors, may your choices be sharp and your voice be even sharper. This podcast is a reflection of lived experience and research in conflict resolution. The Scalpel and Sword is not intended as medical or legal guidance. For personal matters, please consult a qualified professional.