From Apathy to Enthusiasm: Four Lessons for Becoming an Engaging Leader
Written from the perspective of an impressionable trainee, I share with you four key lessons that I identified from effective and enthusiastic leaders during my 3rd year of medical school. During this year of medical school I had a different preceptor nearly every week for an entire year as we are exposed to all of the fields of medicine. As you can imagine, some days were more thrilling than others, and I do believe it was in large part a reflection of how well or how poorly I connected with my leader for that rotation. If you are, or ever plan to be, responsible for the training or mentorship of others, I hope you find this valuable.
Follow along as I take you through some of my lived experiences as I learned from residents and fellows (junior doctors) and attending (senior) physicians and provide insights that I noticed in the best… and less than ideal… leaders. Though this article is written through the perspective of medical student, I attempt to generalize such that these principles and examples may apply to other fields.
Lesson 1: Think out loud.
Trainees will trust you more when you detail your thought process, and is an easy way to make a strong impression on how you operate on a day-to-day basis.
In a field that is becoming increasingly based off of algorithm-driven care (see the Low Back Pain evaluation algorithm from UpToDate just below this paragraph), I’ve tried hard to identify the areas of medicine that require the critical thinking many research-oriented physician love to apply. And in a system where many physicians must balance many patients at once, it can become easy to apply the law of least effort: make sure you get the right diagnosis, use the evidence-based algorithm to ensure you give the right treatment. While this is theoretically effective patient care, it is not the intellectually satisfying application of one’s career that many of us wanted to pursue.
Now, when I saw this type of medicine (not usually this low effort), I wasn’t inclined to think much harder or understand things more deeply. However, when I’d hear an expert describe their thought process out loud, I experienced the desire to learn more and work harder. On my psychiatry rotation, I remember I interviewed a patient with my resident and attending by my side, as we were consulted by the internal medicine team. Our goal was to understand whether this patient had the right treatment plan for managing alcohol abuse. This required us understanding the patient’s motivations to abstain from alcohol, and what plans they had to stick to those motivations, as well as the medications they were on.
When we got back to our conference room, I remember watching the resident and attending discuss the nuances of their impressions of the psychiatric evaluation: “could that pattern of thinking be modulated by the serotonergic effects of his medications? I actually perceived when the patient said xyz that this was a new experience, potentially lining up with a new treatment regimen. I’ve noticed that sort of pattern with previous patients on that class of medications.” I had never yet thought of mechanistically targeted medications (which we students must associate with test answers) as true modulators of specific behaviors. Of course, the coupling of the medication with the patient’s experience, and wishes to improve their ability to work towards their goals of abstaining from problematic substance abuse, was a skill that only can with experience. As a student, me listening to the physicians working through their thought process not only taught me practical information of the use of medications, but also illustrated a concept that gave me much deeper appreciation for the need for experience to deliver the best service.
It is very easy for me, and many other trainees, to temporarily experience the confidence in being able to immediately take on the role of someone senior. Thinking out loud not only demonstrates your expertise and experience but shows trainees that they have a lot to learn beyond the textbook.
Lesson 2: Take the time to understand your trainee’s background and goals.
The subsequent time you must share insight can be tailored to maximize benefits of your interactions.
Not much began to annoy me more than “oh em gee, this case is such a good one for a medical student!” What this meant is that the patient had already been worked up by another service (usually in the emergency department) and the treatment plan had already been devised. In other fields, I imagine it is the projects that your boss or another team hands you that just needs you to complete it… necessary but not enjoyable for someone working with your team for a few days… This type of “mentorship” or “training” assumes a one-size-fits-all approach — assumes that every individual has the same level of understanding and same goals out of being in a job. What I’ll argue is more effective, is spending the brief amount of time to ask your trainee what they’ve done in the past, and what they hope to learn (and I mean sometimes on an every day basis just ask what they hope to learn directly).
Now, I’m fascinated by metabolism. That is like biochemistry, Kreb’s Cycle, etc. and there is a joke made by prominent doctor turned TikTok comedian Dr. Glauckomflecken that it is the absolute worst thing one needs to know during medical school. Anyway, while on my pediatric ICU rotation, I remember a case where a young guy with refractory seizures was started a new medication (valproic acid) that led to valproic-acid induced encephalopathy. Now, though the mechanisms of this are still not fully understood, it is likely due to some variation of this cascade of events:
Valproic acid’s structure is very similar to the fatty acids that we burn for energy in our body. These fatty acids are imported through our mitochondrial cell membranes by the transporters called CPT1 (outer) and CPT2 (inner). They are named carnitine palmitoyl transferase as they cotransport carnitines and fatty acids (palmitate being the most abundant fatty acid in our bodies). What valproic acid was doing was hijacking all of the carnitines, so that fatty acids could no longer enter the mitochondria and be burned as fuel. What happened in this patient is that his glucose levels dropped, and ammonia levels raised as his body had to burn glucose and amino acids (ammonia being released as glutamine entered the Kreb’s cycle as alpha-ketoglutarate, for example) for fuels in place. This excessive ammonia can cross the blood-brain-barrier and induce swelling within the brain and alteration of neurotransmitters, ultimately leading to a coma. Now, the treatment (other than stopping valproic acid) was to give back carnitine to restore normal fatty acid oxidation.
I FOUND THIS FASCINATING. Over the several days that this patient was recovering in the ICU, I nearly begged the residents to allow me to follow this patient, read up about his lab values and the right treatments, etc. Fortunately, I had residents that were interested in the fact that I had studied biochemical pathways for my PhD and listened to my goals. This definitely was not a “oh em gee medical student case” but I learned a lot, and was able to connect my basic research with real clinical application — the whole purpose of an integrated MD/PhD Program! At the end of the week, I gave a presentation of the pathophysiology of this patient’s condition and resolution, and I think the team learned a lot (at least that’s what they said! See Lesson 4).
Now in this instance I had residents who listened, and allowed me to take on a case they were really hesitant to allow a medical student to take on. I explained how this would help me satisfy one of the biggest goals I had in my training — to integrate my metabolic knowledge to actually helping improve patient’s lives. And it paid off! Of course all of my ideas were vetted before any treatments were made at my suggestion.
When you have trainees, you may have the ability to provide them with an unforgettable and extremely satisfying experience if you take a moment to listen to what they are passionate about, and allow them to pursue it.
Lesson 3: Remind yourself of what excited you to do what you’re doing.
Aligning yourself to your intrinsic motivations will allow you to exude enthusiasm even during the monotonous parts of the day.
Why are you doing what you’re doing? Hopefully when you are advising other trainees and mentoring people in a particular field in which you are an expert, you have some reason other than security and money to be in a particular field. If not, that’s honestly fine too! But for the sake of this lesson, let’s pretend you really do have a greater ambition that your career is able to help you accomplish.
I observed that mentors who convinced me that they truly believed they were working in accordance with their life mission, I was in awe and inspired. The fact that if these people could be doing anything in the world it was this, was very powerful! Once again on my psychiatry rotation, I met an attending who had previously worked as an OB/GYN for nearly 14 years, who decided to go back to residency (that is do 4 more years of training) just so they could switch careers and become a psychiatrist. Now with that sort of history I had to ask: “why did you do it?” I probably asked her several times throughout my couple weeks with her because this was such a seemingly big career move. I remember how casually she would simply say: I think this is the way that I can help people in the way that I want to help people. She thought that psychiatry allowed her the best balance of intellectual satisfaction (because not every case fit within an algorithm framework), as well as direct patient care — I feel like Psychiatry is one area of medicine where you TRULY need to get to know a person in order to best help them (it’s a bonus if you do in other fields, and if your doctor does that, I think they must be a fantastic doctor!).
I won’t ramble too much on this particular lesson because I feel it is straightforward, except the fact that hearing her story and the reason she made such a huge life decision to do what she felt was helping her accomplish her mission in life made me inspired to choose that career! When I knew that she had reasons to be doing what she was doing daily beyond having a job, she didn’t have to tell me why she was excited every day. I am fortunate to have had many other mentors in my life that demonstrated this as well, and have definitely helped me become the person I am today.
I challenge you to try to find a way to convince your trainee (and perhaps yourself, especially on tough days!) that you are doing exactly what you want to do in life!
Lesson 4: Encourage questions and remain open to new interpretations.
If you see every interaction with an excited trainee as an opportunity for you yourself to learn, prepare for frequent influxes of creativity and new ways to understand problems.
In research settings, in my previous labs and in many others, it is very simple to say “well this is the way we always did this.” To an impressionable young trainee, this isn’t always the most satisfying answer. Now, there are two ways to continue the conversation when a trainee asks (why do we do it like this): finish it with the above response or follow up with: “can you imagine a better way to do it?”
Now imagine the trainee comes up with a way to save hours a day because they read about this new Python package that came out and can automate what researchers had been spending years doing. Now this would be a nice, immediately actionable and helpful reply!! And sometimes this does happen! Otherwise, you might just stimulate a very interesting discussion!
I remember while rotating on the Liver transplant service, one of my attendings was a physician-scientist herself, and challenged me to come up with a better solution when discussing the treatments for hepatic encephalopathy. Patients with liver cirrhosis (end stage liver disease) have complex pathophysiology that ultimately leads to reversal of blood flow from their portal system (blood flow from gut to liver) entering the systemic blood system. One of the consequences of this is that gut bacteria (the microbiome) that produce ammonia can spill this ammonia into the blood stream and guess what… lead to alterations in neurotransmitter function and occasionally cause brain swelling. Because this is more chronic than the valproic acid problem, usually it does not lead to coma because the brain can compensate to the added ammonia (perhaps by effluxing myo-inositol to ensure that too many metabolites don’t occupy the CSF at once).
So, the problem is, how do we prevent this ammonia from getting from the gut into the blood stream, then leading to altered behavior (hepatic encephalopathy)? The current treatment is to give antibiotics that clear these gut microbes and laxatives that facilitate clearance of the GI tract. Now it isn’t a very glamorous treatment, to just come to the hospital when your confused and be made to have diarrhea while you become less confused. These patients come back somewhat frequently because it is difficult to keep up with this regimen at home!
I thought perhaps you can scavenge the ammonia from the brain, perhaps using an ammonia scavenger in the CSF, so that no matter how much ammonia enters the CSF, a scavenger can clear it and bring it back to the liver or kidneys for excretion. Perhaps this is a decent idea, perhaps not, but at least it got my attending to think of a solution that was not obvious after 15 years of practicing medicine. We don’t have a start-up or anything coming from it, but maybe your next idea will come from an impressionable trainee with a new perspective that wants to solve a problem.
All you have to do is ask!
In summary:
1. Share your thought process to build trust with trainees and make a strong impression.
2. Understand trainees’ backgrounds and goals to tailor your insights for maximum impact.
3. Align yourself with your intrinsic motivations to maintain enthusiasm during the monotony of work.
4. Encourage questions and remain open to new interpretations to foster creativity and continuous learning.
Let me know in the comments if you liked any part of this, could leave anything out, or would like to hear more content about anything in particular! Thanks for reading!
