A urologist’s looking glass: Why self-awareness is vital

During my second year as a urology resident, I walked into my mid-year evaluation meeting with my chairman, threw my hands up in the air, and told him I wasn’t happy with how I was operating. When I later reviewed my chairman’s dictated letter regarding our meeting, he wrote, “She has a lot of self-awareness.” While the remainder of the letter was also very complimentary, this single phrase really stuck out and was perhaps the most meaningful comment in the document.

Self-awareness is fundamental in our everyday lives, regardless of our profession. As urology residents, it affects the way we learn, teach, communicate, and assess our own performance in the operating room. It dictates the relationships we have with our patients, our colleagues, and our bosses. But what does it actually mean to be “self-aware?”

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 “Self-awareness involves deep personal honesty. It comes from asking and answering hard questions,” wrote the late Stephen Covey, the author of “The 7 Habits of Highly Effective People.”

I have thought about this topic time and again, especially as it relates to how one performs in the operating room. I can remember myself saying, on countless occasions, “That tumor was really hard to reach,” “That tissue was really inflamed and difficult to dissect,” or “That aspirin really made the case bloody.” It’s possible that these cases, for various clinical reasons, were difficult. But what if instead, they were difficult due to my lack of surgical skill? When should we stop blaming our patients, their diseases, or other circumstances and start blaming ourselves?

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When trying to tease out what makes a surgeon perform well in the operating room, I asked the very people who watch me operate: my urology resident colleagues and attendings. In so many words, my colleagues echoed the same sentiments.

I particularly liked how Christopher Long, MD, a new pediatric urologic attending, put it: “The person is prepared for the case-has read on the disease process, is aware of the anatomy, is generally aware of the intended operation, and is also aware of alternatives. During the case, they are trying to anticipate moves, next steps, etc. and are really trying to act as though they were the surgeon for the patient. Then at the end, they write what they learned in the case-even if just one small thing-to make themselves better.”

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In short, do I know the disease process, the relevant anatomy, and the steps of the operation? Do I have enough insight on my surgical skills to come up with a way or ways in which to do better next time? If these are the skills on which I am judged every single time I place a cystoscope into someone’s bladder or tie off a blood vessel, then this is how I should assess myself every time I perform one of these maneuvers. When I am really honest with myself, it actually becomes very easy to answer each one of these questions. Although I am not always happy with my honest answers, I think this is what self-awareness is all about.

An incredible thing happened to me this week. I was assisting one of my fellow residents during a robotic prostatectomy while she was operating on the console. We were having particular trouble clipping the prostatic pedicles, which involved her dissecting out portions of the pedicles and my using a laparoscopic clip applier. After the operation, my colleague sat in my office and we had a candid discussion about how we thought both of us could improve during this portion of the case. She called me the following day after having reviewed a video of one of our attendings clipping the prostatic pedicles, and we came up with a plan in which each of us would try something different the next go-around.

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It was a great example of how two senior-level residents critiqued their and their team’s performance in a productive way in order to improve their efficiency in the operating room.

As residents, we have 5 to 6 years to learn how to operate with leaders of the field a mere step stool away. We owe it to our attendings, our patients, and ourselves to make an honest assessment of our capabilities, to ask for help when we need it, and to make an honest effort to improve so that we may provide the exceptional care our patients seek and deserve.