From the April 21, 2023 issue of the Transformational Times
Fellowship Training: Mindfulness, Coping, and Lymph Node Dissections
Lindsey A. McAlarnen, MD, M.Sc.
Dr. McAlarnen is completing her three-year Gynecologic Oncology fellowship at MCW. Along the way, she has been involved in the REACH Curriculum and the Kern KINETIC3 Teaching Academy. In this essay, she reflects on her three-year journey, including learning to pause for mindfulness as a busy physician and surgeon, and offering some words of thanks...
A few weeks ago, my co-fellow and I joked about how different fellowship was from residency.
Catching two clinical fellows sitting in our shared academic office is a rare event. Our office is more of a glimpse into the day a co-fellow is having than a gathering space. Lukewarm, once-iced coffee sitting on a desk, a cold breakfast sandwich with one bite taken, or empty research tubes set on the keyboard as a tangible to-do message from the clinical research team, are unwritten memos of leaving in a rush to “take care” of a clinical event or dashing to the OR.
I grew to tangibly feel in my body what my co-fellows were experiencing by reading their eyes through a face shield and mask in the OR, or by translating the nearly untouched Starbucks drink on their desk.
This common bond led to a great understanding and moment of mutual appreciation when I muttered, off-the-cuff, that my experience of gynecologic oncology fellowship is basically a lesson in “Mindfulness, coping, and lymph node dissections.”
Coping came first—starting fellowship in a new program at MCW as the first fellow ever in July 2020—was quite an experience. I graduated from OBGYN residency on a Friday, moved to Milwaukee Saturday, and came to the Froedtert/MCW campus Monday to get my ID badge and tour the OR. There were scant orientation modules, no in-person meetings, and after being brought to the 4 Pavilion nursing unit, I was sent on my way to being the first gynecologic oncology fellow. With little direction and no one ahead of me, I learned mostly through missteps or what I did wrong.
Enjoy the little things in life because one day you’ll look back and realize they were the big things.
– Robert Brault
What I do—and do not—remember from my first year of fellowship
I block out the majority of memories from that first year of fellowship—as a protective mechanism. When I reflect on it, I don’t know how I survived being on-service for ten months, with "breaks" for rotations in the surgical ICU and with radiation oncology.
I do remember and reflect on what got me through this time—my mom’s meal prep sprints that stocked the freezer after Christmas, my high-school-aged neighbors whom I employed to walk my dog daily, and whenever I got stuck at the hospital late. I remember first feeling a part of the team after joining the surgical ICU service in October of 2020—our collective sense of the unknown as we read news details of protests in nearby Wauwatosa—and mentally preparing for the possibility of an increased ICU patient census.
During my research year of fellowship, I had the chance to engage in various teaching opportunities, the most rewarding of which was serving as clinical faculty for a small group of M1-M2s in the REACH (Recognize, Empathize, Allow, Care, Hold) curriculum. This experience represents a turning point for me, an introduction to mindfulness as a part of my clinical practice, and the point in my training—albeit as a PGY6—where I learned to pause and incorporate awareness into my usual tasks as a busy physician and surgeon. When I think of the whole of REACH, the amazing students it introduced me to, and Dr. Cassie Ferguson, the meme or car magnet of adopted pets comes to mind: “Who rescued whom?”
Putting mindfulness into action
Back in the clinic, wards, and operating rooms this academic year, I have a different appreciation for my patients, colleagues, and faculty. Trying to practice mindfulness in clinical practice is a work in progress for me, but I have been able to take ‘memory snapshots’ throughout the year that serve to reinforce the reasons I went into medicine, my subspecialty, and function as pearls of inspiration for the tough times.
The snapshots most frequently involve images of relationships I’ve made—like with the 4P charge RNs and our daily morning ‘RTL’—run the list—through the nurse’s station window—or counting on the smile and predictable greeting of the employees who passed out stickers granting access between Froedtert and the HUB during 2020-2022.
When I reflect on these relationships and snapshots, I often recount the hundreds of people who have helped me reach this point in my career. From my 2nd grade teacher at summer writing camp to the undergrad advisor who I distinctly remember telling me, “People like you don’t get into medical school,” to my medical school classmates who are each doing different, yet amazing things every day in their own practices across the world—each has had a profound impact on my knowledge base and training, but more importantly on my character as I grew from a fifth-grader dreaming of being a pediatric orthopedic surgeon to a thirty-something gynecologic oncologist.
The summation of these experiences and relationships shaped me—both the good and the bad—and I hope to continue to grow and evolve as a person and surgeon throughout my career.
You see things, and you say, "Why?" but I dream things that never were, and I say, "Why not?"
– George Bernard Shaw
That I am almost a fellowship-trained gynecologic oncologist is hard to fathom. As a resident at Loyola University Medical Center, gynecologic oncology seemed like the ultimate specialty to me. The Gyn Onc faculty expected us to treat critically ill patients, perform bedside procedures, assist on debulkings to R0 (surgically removing all evidence of residual cancer), understand the evidence behind basic treatment of the most commonly diagnosed GYN malignancies, and have a bedside manner and relationship with patients in the clinic such that they saw you as "their doctor."
Thoughts as I complete my fellowship
Looking at my three faculty from residency, I never imagined I could be them someday. I doubted my ability to learn the chemotherapy and radiation techniques needed to treat gynecologic malignancies; the amount of clinical acumen required scared me. To the mentor who said, “You can,” thank you for believing in me.
Surgery is a whole different ballgame. My goal during my chief year porcine lab was to laparoscopically remove a lymph node, and my "graduation present" was being granted the opportunity to fire an EEA stapler.
Now these memories make me laugh. Lymph node dissections of the pelvis and para-aortic region are the cornerstone of Gyn Onc fellowship. I’ve learned and removed lymph nodes via laparotomy, robot, and laparoscopically. The technique requires dexterity, precision, and there are multiple “correct” ways to perform a lymph node dissection.
I’ve come a long way surgically during my fellowship, and I appreciate every surgical assist, tech, circulator, member of the anesthesia team, faculty, resident, student, environmental services staff member and, most importantly, every patient who has provided manual assistance, tips, tricks, or opportunities to operate and teach in the OR. The OR has been described as "the most vulnerable place in the hospital," and I can appreciate this statement from the perspective of both the patient and the surgeon.
To those who have watched me struggle, become frustrated, or be unable to accomplish something, thank you for your patience. To the great surgeons who have shared their technique and strategy, thank you for your wisdom. To the few who have shared the lessons they have learned in the OR from their own mistakes and surgical growth, this has contributed the most to my professional development as a surgeon. Thank you.
Surgery requires diligent reverence. May I go forth from my training to mindfully operate and teach those with gynecologic malignancies and those caring for them.
Lindsey A. McAlarnen is a third-year fellow in the Division of Gynecologic Oncology in the Department of Obstetrics and Gynecology at MCW. She is a member of the KINETIC3 Medical Educator Track.