[00:00:00] Dr. Cifu: On today's episode of The Clinical Excellence Podcast, we have Dr. Ava Ferguson Bryan talking about medical training so far.
[00:00:12] Dr. Ferguson Bryan: I mean, all of medicine is a hard job, but surgery is unusual for the fact that you walk into it with, you know, for the vast majority of people, no training in how to do this very high-stakes thing that at the end of it, you have to be able to do safely and independently, in many cases in the middle of the night and...
[00:00:45] Dr. Cifu: We're back with another episode of The Clinical Excellence Podcast, sponsored by the Bucksbaum-Siegler Institute for Clinical Excellence. On this podcast, we speak to patients and doctors about all aspects of excellence in clinical medicine. Today, we continue our series talking to people in various stages of medical training.
I'm Adam Cifu, and today I'm joined by Ava Ferguson Bryan. Dr. Ferguson Bryan is a general surgery resident at the University of Chicago. She's originally from Dallas and did her undergraduate work at UT Austin. She holds a master's degree in humanities from the University of Chicago and in public health from Harvard and an M. D. from the University of Chicago's Pritzker School of Medicine. During residency, Ava spent two years as a research fellow at the Center for Surgery and Public Health at Brigham and Women's Hospital, Harvard Medical School, and was an American College of Surgeons MacLean Center for Medical Ethics surgical ethics fellow.
She will complete a breast surgical oncology fellowship after graduation and intends to pursue an academic career focused on oncofertility. Ava, thanks so much for joining me.
[00:01:50] Dr. Ferguson Bryan: Thank you so much for inviting me to do this.
[00:01:53] Dr. Cifu: So you're a resident in general surgery. First, kind of how did you end up here? Like, how did you end up in medicine and then why surgery, I guess?
[00:02:01] Dr. Ferguson Bryan: I had a pretty wandering path to medicine, as I think is pretty common at Pritzker which was described to me once as a safe space for bent arrows. And I think that is true in my experience. So I was an English major in college, English and art history. And I thought that I was going to be an English professor. I thought I was going to research and teach Virginia Woolf. And I started a graduate program in the humanities here at U of C many years ago and realized about two weeks into it that I was in the wrong life. And so I left. I spent a year, left with masters, did my medical prerequisites.
At the time, I had a couple of sick grandparents and I think through sort of processing their illness and some volunteer work I did with hospice organizations, the bug was put into my brain that maybe I wanted to be a physician. And so I spent two years back at the University of Texas doing my premed requirements. Moved to Los Angeles for a year, mostly because my sister was out there, and it sounded fun while I took the MCAT and applied to medical school. And then ended up back here for medical school and surgery was, I thought, the literal last thing that I was going to do with my life. In fact, I got the recommendation as we were putting in our requests for third-year rotation orders to put the thing that you knew you didn't want to do at the end of the year, and so I knew that that was surgery. And then I got there and, you know, felt a sort of affinity for and kinship with the surgery residents that I think was really... I think the majority of why I chose surgery but you know, I think it's... Many people who end up surprised by surgery will talk about sort of the magic of the operating room and you know, what a special space that is. And the idea of being, you know, sort of transformed from this you know, fallible human being into somebody who is capable of doing such, you know, remarkable technical tasks, I think I really fell in love with, and so that's how I ended up in surgery.
[00:04:16] Dr. Cifu: We have a lot of premedical and medical students who listen to the podcast. And I think for a lot of people, it can be, I don't know, kind of scary in the third year when you have one of those realizations and a big shift in what you're expecting. Even though it sounds like it was fairly obvious to you, and I actually remember having these conversations with you in medical school, was it still sort of frightening and like took a little bit of courage to say, "Wow, I'm going to shift and do this thing that I hadn't really pictured myself in?"
[00:04:49] Dr. Ferguson Bryan: I think that it did, although I was so overwhelmed by how much I loved surgery, that is that... You know, what I told myself was the rest is just paperwork. Although I had conversations with many of my mentors, particularly in surgery, about what it would mean to be a woman in surgery, what it would mean to start a family while I was a surgical trainee because as you know, my path to medicine might indicate I am, you know, older than I think most surgical residents, you know, go straight through. It is unlike Pritzker, a space where being non-traditional I think is a little bit less common. And we had a lot of conversations about that and I knew it would be difficult, but at the end of the day, it was so clear to me that surgery was what, I felt, chose me, that there was really no two ways around it for me and I just had to commit to trying to figure out how to make the rest of it work.
[00:05:54] Dr. Cifu: I thought you were going to do a wand chooses the wizard joke.
[00:05:58] Dr. Ferguson Bryan: Oh, it was a missed opportunity.
[00:06:03] Dr. Cifu: So let's talk about the training in surgery, itself. Obviously, you know, as a medical student, you see what the residents do. You sort of understand to some extent what you're getting into in residency, though often not in career but has kind of surgical training been what you expected? Has it even evolved during the, you know, almost decade that you've been in it for?
[00:06:28] Dr. Ferguson Bryan: Yeah, I think it was... I think I probably got a pretty accurate idea of what surgical training was while I was a medical student. I think what I did not appreciate as a medical student, and I think what is maybe impossible to appreciate as a medical student, is just how long surgical residency lasts. You know, truly what, you know, seven years, or in my case, eight years, you know, of your life feels like, and the sort of sacrifices that that requires for the rest of your life as you go along. And that, you know, now being at the tail end of my residency, I am feeling the wear and tear of, I think a little bit more than I fully appreciated that I would as a medical student but you know, one of the things that I think I had a pretty accurate sense of as a medical student was that residency was going to be this, you know, extremely difficult, arduous, intense, time-consuming period of my life, but then as an attending, I would have much more control over my life and my schedule.
And my husband is an attending surgeon now at the beginning of his third year of practice. And I think, you know, having watched it from the perspective of a spouse, that really has borne out to be true.
[00:08:10] Dr. Cifu: As I hear you talk about it on the one hand, it's so admirable to think with, you know, a very sort of, I don't know, clear eye about what the future is going to be and think intelligently about, you know, your specialty based on that, right?
On the other hand, you know, I sometimes cringe when those aspects of a career are what drive people most. And I think sometimes people give up their professional dream because of what it's going to take getting there or what it's going to be once you're there. I think it probably just takes a ton of honesty with yourself to know what's right.
[00:08:52] Dr. Ferguson Bryan: For sure. And I do think that surgical training is too long to sort of white-knuckle it through. And this is something that I have told many medical students who say.... You know, I'm going to be a breast surgeon. And so I've had multiple medical students say to me, "Oh, I loved breast surgery, but I'm not sure that I really like the rest of general surgery."
And I think seven years is too long. And, you know, 80 hours a week of general surgery for seven years is just too much of your life to, you know, be into the "Well, it'll be better on the other side." You have to be able to get into the mindset, at least, somewhat of residency being, you know, enjoyable or sustainable to make that work, I think.
[00:09:48] Dr. Cifu: Right. It's this balance of we only get really good at the things that we love, right? That you can sort of tolerate doing for a ton of time. But right and obviously, I'm going to say, you know, there's something really important about being a generalist. And I worry about medicine getting too specialized, but then on the other side, you know, do we burn out some great people turning them into generalists or giving them generalist skills when maybe it's not what they need in the long term? They're all hard questions.
[00:10:18] Dr. Ferguson Bryan: They are, for sure. And I think surgery is definitely still a field that has a real romance with the idea of being a generalist. And, you know, there's a reason why I have to be, you know, the trauma surgery chief and the vascular surgery chief, and then sit for oral boards in which I'm going to be examined in the same way as people who are going to go out and practice those fields in order to, you know, be a breast surgeon, so...
[00:10:43] Dr. Cifu: So this is probably a perfect transition to sort of my plan: the next question. You know, I've been involved in medical education for kind of ever, and I'm always interested in like, what we can do better. And I'm already getting a sense of what you'll say, but like, what do you think we've done really well? Like, what has worked for you? And then what things, if you became, you know, I don't know, medical training czar, surgical training czar, would you say, like, this has got to change?
[00:11:09] Dr. Ferguson Bryan: Yeah. It's a tough question because I do think there is... You know, at the end of the day, surgery is a hard job.
I mean, all of medicine is a hard job, but surgery is unusual for the fact that you walk into it with, you know, for the vast majority of people, no training in how to do this very high-stakes thing that at the end of it, you have to be able to do safely and independently in many cases in the middle of the night and it matters. And I think the training needs to be hard to a certain extent, to get you there. I do think that there is still a lot of the mentality that surgery is not hard to do, it's hard to get to do. And so a little bit that, you know, you have to put yourself through the wringer to prove that you really want to be here. And I think being honest with ourselves as a field about which parts of our training fall into which of those camps and being very ruthless about sort of cutting out what isn't truly necessary to make a safe surgeon. You know, it's interesting. I think this conversation, especially, in light of what I understand from an outsider's perspective to be the ACGME's intention to curtail work hours even further than 80 hours a week. And I think, you know, surgery... We're going to have to be very honest with ourselves about what actually is important about our training and what isn't important about our training. And the rage in surgical education right now are entrustable professional activities or EPAs, which the American Board of Surgery is just starting to roll out, and the idea being that this old mentality of, you know, you have to do 48 out of 52 weeks where you're sitting in the hospital waiting for consults to come in or, you know, or whatever. It's time logged versus, you know, attending certification that you are competent in, you know, the things that we as a field have deemed you know, the essential, you know, procedures that together make a general surgeon. The spirit of the field and of surgical education is starting to move in that direction but, you know, very early stages and it's going to be decades, I think, before that is usable in any sort of a robust way that replaces this old mentality of, you know, surgery is a hands-on sport. Yeah.
[00:13:51] Dr. Cifu: I've said with another one of the trainees that I've talked to that I think one of the things that is much harder now than it was in my day is that you really do have to be kind of more intentional about the learning because when you're just being overwhelmed with numbers, you kind of can't escape learning it, but when the numbers are more limited, you actually have to be deliberate about like, am I getting this?
I wonder, hearing you talk is interesting because certainly, we're going through the same thing on medicine, that like, boy, you know, do you have to manage, you know, 50 cases of heart failure when you're really good at it after ten? And it may even be easier to track for a surgical trainee. And you could imagine saying like, there's a minimum, but not everybody gets good at it after ten. And maybe you don't actually... Ten is not enough to see the complications, you know, that are going to come up. And so it's like, you have to do so many numbers and then you have to be assessed beyond that to say like, is ten enough for you? Is 15 enough for you? And they're going to be people for whom 30 is enough, you know, that have to get there. I wonder if we're more intentional about it, if we end up shortening training or lengthening training.
[00:15:04] Dr. Ferguson Bryan: And that's the question that's, you know, on the table. And I think the idea eventually is that for some people it will be shorter and for some people, it will be longer. We had a grand rounds a couple of months ago for somebody who had been sort of foundational in the development and rollout of this sort of EPA pilot for the American Board of Surgery. And she presented data on the different domains of the EPAs. And many of them are procedural, but one of them actually is surgical consultation. And so, you know, the sort of workup and diagnosis and management of surgical disease. And the data that she presented suggested that the plateau is actually around PGY three year whereas for a lot of the procedural EPAs it was PGY four or five.
And so I think there also are implications in terms of, you know, maybe our PGY fours and fives don't need to be involved in surgical consultation. Maybe we can transition from, you know, taking, you know, in-house calls where the idea is we supervise mid-level residency and consults to more, you know, home call where we come in for the operations if that's where more learning needs to take place towards the end of residency and you know, to my mind, that is also potentially a way of, you know, sort of winnowing down surgical residency to what really we need.
[00:16:38] Dr. Cifu: It's interesting too, on the other side of the career, you know, and I think about that. I think about then the things that you actually start to get worse in with time, right? And when you first started mentioning consultation, I think about the things that you get to a point where you feel like you can do everything and you are a talent in knowing when you should call in help probably declines. And I think that's probably a flaw, you know, in my care now, which wasn't 20 years ago. So some of these EPAs should probably follow us throughout our whole career.
[00:17:12] Dr. Ferguson Bryan: Yeah, it's the CME recertification.
[00:17:17] Dr. Cifu: Okay. So I got to get to the women in medicine angle somehow, because if I'm talking to a woman in surgery and don't, people would be like, "Oh, what are you missing out on?" So honestly, I think we're at a time where we're beginning to worry about not enough men going to medical school but there's certainly still a real dearth of women in some fields, general surgery definitely being one of them and definitely, definitely true in leadership positions, especially in academic medicine. So just, you know, kind of stepping back and thinking of yourself, you know, as a woman surgeon. I don't know, what's your experience been like? Has it been okay? Does it seem harder than the men? Has the sort of, you know, work-life balance thing been more challenging for you? I don't know. How do you look at it?
[00:18:05] Dr. Ferguson Bryan: For sure. So I'm a woman in surgery, I'm also somebody who has had two children during residency and about to have a third child during residency, and I think, in particular, for me that transition from, you know, being a woman in surgery without children to a woman in surgery with children, especially, you know, a pregnant trainee in surgery, you know, a mother of very young children in surgical training, has really changed the way that I think about this question. And it also has changed how I talk to medical students who are interested in surgery and in retrospect, looking back on the conversations that I had with my mentors in medical school about what it would mean to choose surgery and some of the things that I had alluded to earlier in the conversation about, you know, the wear and tear of such a long training on one's life outside of the hospital are really colored by that.
So I think that surgery in general, and certainly, academic general surgery, which is the corner of the field that I'm most familiar with, in spirit has made this tremendous and really admirable dedication to diversifying the field in many, many senses, and has actually, I think, done a pretty decent job of recruiting residents. And now at this point, you know, through the training pathway junior faculty who are not just, you know, 26-year-old white men. That said, I think that we have not made the changes to how surgical training works that accommodate the needs of trainees who are not, you know, single 26-year-olds.
[00:20:30] Dr. Cifu: It'll be, I think, very interesting because it sounds like, and stop me if you think I'm assuming too much here, but it almost sounds like you know, the changes that have been made so far are in a way the easy changes. Like, okay, we're going to be more intentional about recruitment. And we're going to be a little bit more intentional, you know, about lifestyle and maternity leave and so on and so forth but maybe there need to be bigger changes in actually the training itself to make this equitable, you know, for the long term.
[00:21:05] Dr. Ferguson Bryan: Sure. And I think that part of the idea of surgery transitioning to EPA is to give trainees a little bit more flexibility but I think it's a long ways away. And you know, there have been policies that have been instituted that have made surgical training a little bit more flexible. Like for instance, the American Board of Surgery has what they call a five-in-six option. So five clinical years in six calendar years, which I'm taking advantage of to facilitate these extended maternity leaves. And so, for the listeners, my first baby was born while I was in our required two years of research, which was easy. It's a common time for surgical trainees to have children if they're going to do it in residency but for my second and then my upcoming third babies, I knew that the four weeks of extended training, which is what's offered to us if we don't want to extend our training such that we have to sit for the general surgery written Boards a year later than when we graduate, I knew that four weeks was too short. And so the options were basically four weeks or a year. And so I knew that I wanted multiple more children, so I split up that year into two six-month blocks. And the American Board of Surgery was in this program and the American Board of Surgery was super supportive of me doing that but it's interesting because then, you know, we talk about how operationally that happens for trainees and get into the just absolute morass of, you know, parental leave and childcare issues that plague almost every job in this country. For instance, I just learned that at U of C, the GME only supports one true fully paid maternity leave per training program, which might... You know, I think is, on principle, cruel no matter the length of the program but I think it's very different when we're talking about a one-year fellowship or even a three-year residency versus in my case, an eight-year residency in which it's preposterous. And then, you know, childcare is quite frankly too expensive to afford on a resident's salary. And so I think that programs, in particularly, surgery programs, because the training is so long, because it sort of runs the gambit of most people's, you know, practically speaking, their reproductive years, it being then incumbent upon surgery programs and probably on leadership at the American Board of Surgery level to help advocate for, you know, things like multiple fully paid maternity leaves to support people taking advantage of this five-in-six option. You know, paid child care that actually runs the hours of a surgical trainee's day, which is, you know, very rare and does not exist at this hospital.
You know, I think that that's where the rubber hits the road, and you know, we can say all day long we support surgical trainees having families, but unless we make it practical for people whose, you know, spouses are not attending thoracic surgeons to take a bunch of unpaid leave, then, you know, we're really not doing the thing.
[00:24:53] Dr. Cifu: Right. And even the things that you say are easy, you know, like, "Oh, I can have children during my research years," is easy if it works, right? But not everybody's lucky enough to say, "Ah, this is when I'm going to get pregnant," and they get pregnant.
[00:25:07] Dr. Ferguson Bryan: Exactly, exactly.
[00:25:08] Dr. Cifu: So the complexity of this can spiral very quickly.
[00:25:12] Dr. Ferguson Bryan: Oh, absolutely. And something that I, you know, didn't fully appreciate before getting, you know, into the era of my life where I was, you know, actively thinking about having children is that there are some states where, you know, access to assisted reproductive technology is covered by insurance by law and some states where it's not. And I think it's very surprising, for instance, California is not. And you know, I think my bias would be to assume that if it's a blue state, then it would have those supports. And it's something that I never would have thought to ask about or look into as a medical student that is so important for so many people.
[00:25:57] Dr. Cifu: Like it isn't hard enough already to figure out how to rank programs but actually to start considering...
[00:26:03] Dr. Ferguson Bryan: Exactly and I was thinking about actually this conversation and I sort of joked to myself that I should do like a user's guide to, you know, fertility and residency and that being sort of one of the many questions that I think should be added to the mix.
[00:26:23] Dr. Cifu: Well, we'll end here with a book idea for the future. What to expect when you're expecting as a surgical resident?
[00:26:31] Dr. Ferguson Bryan: Yes.
[00:26:32] Dr. Cifu: So Ava, thank you so much for joining me today. I really appreciate it.
[00:26:38] Dr. Ferguson Bryan: Thank you so much for inviting me to be a part of this.
[00:26:41] Dr. Cifu: So, thanks for joining us for this episode of The Clinical Excellence Podcast. We are sponsored by the Bucksbaum-Siegler Institute for Clinical Excellence at the University of Chicago. Please feel free to reach out to us with your thoughts and ideas via the Institute webpage.
The music for The Clinical Excellence Podcast is courtesy of Dr. Maylyn Martinez.