Hey y’all -

You know that old advice to dress for the job you want, not the job you have? Throughout residency, I did NOT follow that. My wardrobe was extremely resident coded: rumpled, age-softened hospital-issued scrubs for work, and then gym clothes or loungewear outside of that. It was pajamas all the way down; always ready to curl up in the corner and take a nap. I’ve never been a big makeup person, but I oscillated between the absolute minimum and nothing. When did I last wash my hair, you ask? Lawyer.

So how are you supposed to dress once you finally get the job you want? I’m still figuring that out. I recognize that for a surgeon (and for a lot of client/patient-facing jobs, honestly!) you’re always potentially being assessed, and, I probably should be taking more pride in how I present myself, both inside and outside of work.

Dressing for the office: I’m one hundred percent team scrubs. But unlike my residency scrubs, these are nice, in a variety of fun colors, and have my name embroidered on them. My job isn’t nearly as messy as it was before when I was seeing consults in the ED and changing hospital dressings on the regular, but the last thing I want to be thinking about when I’m taking out somebody’s drain or doing a clinic bleph is whether or not I’m going to have to send my pants to be dry-cleaned after.

I’m still pretty minimal on makeup, but more consistent, and I’m thinking about booking some kind of appointment with a makeup specialist to help me do better in this department (if you have recs, please send them my way!).

I’m also trying to dress a bit more like an adult! Even incorporating “hard pants” (aka jeans and trousers and such) and non-tee shirts. And it’s overall been really nice. There is something—something I think I’d forgotten in my residency years—about going out of the house in a thoughtful outfit, rather than just whatever is clean and soft. It makes you stand up a little straighter, puts a little pep in your step, and it also makes it less jarring if you run into somebody you’re not expecting.

Because that’s honestly part of what I love about living in Philly. It has a real neighborhood feel and no matter where I go, it seems like I run into people I know. Just this week, one of my neighbors caught me sneaking over to the corner store after dark because I wanted something sweet before I went to bed. I was wearing gym shorts and jelly sandals.

Plastic surgery as an industry is—and this may shock you—very focused on appearance. And I recognize that my personal appearance will be read as a reflection of my work…if I don’t look put together, why would you trust me to make you look your best? I suspect this cuts differently for my male colleagues, but would be curious to know what people think on that point.

Here’s where I’ve landed: I will never achieve continuous glam, it’s just not who I am. But I can dress a little more consciously, now that I’ve got a bit more time and space to take care of myself—inside and out.

Talk soon xx

Liz

Hey y’all!

One of the side-effects of surgical residency is that you get desensitized to nakedness. It’s partly from repeated exposure (get it?), but I think it’s also due to the totally different set of mental frameworks that get activated when you see a naked body in a clinical setting.

It’s a code-switch. And when I’m the patient, I don’t really feel that awkwardness anymore either. The last time I saw my (male) dermatologist? I hadn’t shaved my legs in at least three weeks, and I worried about it zero because I KNEW that wasn’t even registering in his brain.

But I realize that nakedness is still awkward and uncomfortable for most people. So over the last few weeks I’ve been working toward a formula for a minimally-awkward plastic surgery consult. Still very much a work in progress, informed largely by conversations with my early patients, but I’d LOVE to hear what you think:

1. Start the consult in the office rather than going directly to an exam room. I’ve personally never liked the idea of a patient meeting their doctor for the first time wearing a sad smock (that euphemistic term “gown” isn’t fooling anyone). Sitting all chilly and exposed on a sheet of crinkly paper waiting to talk about your most personal problems? No thanks!
   
   I want to meet my patient in my cozily-professional office so that I can meet them as they actually present themself to the world. Plus, they get more information about me that way too, by seeing my space and my pictures and my weird rock lamp and such. Finding the right plastic surgeon, as they say, is a bit like dating, and I’m a big believer in the vulnerability exchange.

2. Nice comfy branded robes like at a hotel. As above: nobody feels at ease in a smock.
   

3. Aggressively clear instructions about how naked to get. This is one I’ve struggled with myself in the context of other services like massages and waxing and spraytans and such. Does “everything off” mean underwear too? Can I keep my socks on at least?
   
   As a surgeon, my preference would honestly be that everybody just gets completely naked every time so it’s consistent, but I see how that could seem strange. And I know it’s not totally intuitive! For example, if you’re interested in an arm lift, I can’t examine you in a bra because it’s covering part of your lateral chest and potentially pushing soft tissue in unexpected ways. Similarly, if you’re thinking about a tummy tuck, I need an unobstructed view of how your trunk flows up to your chest and down to your hips and thighs.

   Still workshopping language here but I’ve found that “everything off from the waist up/down” still leaves some people looking stressed, so I think I like saying, for breast consults for example “shirt and bra off but you can keep your bottoms on,” or for tummy tucks, “birthday suit only.”
   

4. Optional disposable underwear. I actually decided to offer these in response to a couple mildly awkward early consult moments. And if I can get a little personal with y’all for a moment, since we’re talking about vulnerability exchange…I, too, do not always wear underwear when I workout. I even occasionally venture out braless. I also, approximately once a month, get my period! To me, a desensitized weirdo and a woman myself, these things don’t faze me one bit, but I see how it could make you uncomfortable if you have to unexpectedly reveal these personal details.
   

   Why can’t people just keep their underwear on, you could very reasonably ask? The main reason is that I have no idea what’s going on under there. Maybe you’ve got a nice seamless barely-there thong (high-five), maybe you have striped cotton boy shorts or lacey pink cheekies (fun, but not ideal!), maybe—heaven forbid—you’re rocking a pair of spanx. Depending on the style, underwear can pinch and pull and shape in ways that distort the aesthetic lines I’m looking at, so I really need to see one of two things: you at your nudeliest, or you in the lightest possible, un-pinchy thong.
   

   So now, if you come to see me, you have two options: totally naked, or if you’d prefer, we provide disposable underwear.
   
   Now I’ve already gotten a few raised eyebrows on this, but I picked this black lace style. My feeling is this: why should I put you in something ugly and clinical when I can put you in something pretty and normal? It’s the same reason I wanted robes instead of smocks/gowns. But I see the counter-argument that what I picked could be viewed as sexualized. I’m ready to concede that awkwardness may be in the eye of the beholder, but would genuinely LOVE to gather more opinions on this point.
   

5. Exam first, then pictures. I initially was doing pictures first just because I tend to get distracted by whatever fun convo we’re having at the end and I forget to take them. I viewed this sequencing as “getting the awkward part over with,” but after talking with a few patients about it I think it’s worth starting with the physical exam instead. The absolute highest moment for potential awkwardness from the patient’s perspective is “the reveal,” when they drop the robe and watch me intently to gauge my initial reaction. Combining that with the camera’s distance and exposure (ha! another one) is kind of a lot. Plus, I find that in the vast majority of cases, after a minute or so, patients relax into the exam, sort of half-way joining me in the code-switch to talking shop. And then pictures are much less of a big deal.

I’m still tinkering with all of this, and I want to know what you think, particularly about the underwear. Are you team lace? Team naked? Do you have a heartfelt defense of the hospital smock?! I want to hear it. You can reply to this email or find me on insta.

Deciding to actually make an appointment to see a plastic surgeon is a brave and vulnerable thing to do. And I don’t think I’ll ever fully exorcise the awkwardness of the plastic surgery consult. But for now, early in practice and with extra time and nervous energy to burn, I’ll keep tilting at windmills.

Talk soon xx

Liz

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Hey y’all!

I took the afternoon yesterday to do some exploring around my work-neighborhood, with the idea in my mind that it would be a way to connect with the community, with local businesses, and to just get a better feel for what it’s like around here. Up til now, I’ve mostly targeted other docs with my networking efforts—always pre-planned and always armed with treats—but for this lil experiment, I decided to go with a more organic approach.

Fine. I’ll just say it like it is…I went shopping.

I was completely charmed by two local stores in particular:

1. Hope Chest, a no-nonsense specialty lingerie store where I met Donna who has been scooping and cinching Mainline women into bras that actually fit for 30 years; and

2. Skirt, a local boutique carrying some of my most aspirational brands (la ligne, l’agence, staud…I cannot pronounce a one of them but I love their stuff) where I met Jen, who put me in an outfit that I’d never have selected myself (a cropped brown sweater and striped silk pants? Who am I!) that I am absolutely dying to wear the minute the air turns crispy.

Despite the obvious delights of this adventure, shopping in this weird semi-professional capacity showed me a side of myself that I know I need to work on. I reflexively say not-that-nice things about my body when I’m in any kind of sartorial situation.

(Lemme just get it out real quick: long torso broad shoulders un-dainty ankles a forever convex lower abdomen and my right breast is slightly bigger than my left)

Ok there I said it.

This is a terrible habit, to neg yourself when somebody else’s attention lands on your body, and I know I’m not the only one who does it. But it’s so completely at odds with how I think and talk to my patients about their bodies…and really how I view other people’s bodies in general! If I try to dig down on it, I think it’s a misguided self-defense mechanism: naming my flaws before somebody else can…as if that keeps me in control.

I view myself as being in the body positivity business. I know how that sounds given that I spend my days pinching and prodding people’s sensitive areas and thinking about how I can “fix” them, but it’s true.

To me, there’s nothing more hopeful and positive than choosing agency in any area of your life. Taking the hand you’re dealt and asking—even if you’re just asking—if you could have more or better. Taking the bold step to do something big for yourself (because if there’s one thing I know about plastic surgery: we women are doing it for ourselves).

Maybe I’m drunk on the industry Kool-Aid…if you think so, please feel free to let me have it. But fwiw here’s my public pledge: I am going to make a renewed effort to quell my negative self-talk and to practice what I preach when it comes to self-image and the complicated, inescapable reality that we are not brains in jars but rather fully-integrated body-having beings. Messy, imperfect, mutable, miraculous, beautiful.

Talk soon xx

Liz

P.S. go see Donna and Jen ;)

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Hey y’all!

I have this delightful Muji notebook that I’ve been using to make my to-do list every day (yes, with checky-boxes…residency habits persist). I like that it’s one page for each day, and I like that it has the dot-grid, because that makes it more fun to draw checky-boxes.

At the top, I write “day X” and the date, and then I write what has turned out to be not so much a list of tasks, but more like a brain-dump of ideas, questions, problems, and yes…a few concrete tasks.

Today is day 10. I looked back at my first 10 pages, and overall, only about half of the boxes are checked!!! Resident-me would be APPALLED.

Starting in practice has been exciting and fun but also disorienting. It’s a totally different way of working than what I’m used to—better in so many ways!!—but I’m definitely still finding my footing in terms of how to structure my time and what to prioritize.

I am also trying to learn how to relax. My husband more or less staged an intervention on me over the weekend, pointing out that I need to stop trying to fill every moment of my life with something “productive.” That drive is part of what’s made me successful, but something about the end of residency…feeling like I was trapped and spinning my wheels…left me with this revved-up engine in my brain that I can’t easily turn down, and my husband is right that it’s maladaptive for me to try to do everything, all the time, all at once.

(to be honest, it’s been going on much longer than that…in high school, back when violin was my thing, I had a sign on the ceiling above my bed that said “people in China are practicing”)

Intellectually I know that we humans need room and space to stop and think. To actually recreate, not pretend like your side-gig is actually a hobby. To relax and read a non-productive book and listen to the birds chirping. I know that if I want this career to work for me as a human being, I need to accept that I can move fast and be successful without turning every single moment in my life into a race against myself.

All of which is to say…I’m doing a medium-job of managing the doldrums and slowness that characterize the early days of any new job, particularly for doctors.

In my first two weeks I’ve seen about a dozen consults, and really enjoyed figuring out how I want to structure those encounters and manage the flow of the patient’s experience of our time together. That part has been very rewarding, and a reminder of what I love about this job.

If you take a step back, this job is super weird!!! You, the patient, pay money to spend an hour with me: a stranger you learned about on the Internet. You tell me what you hate about your body in the hopes I can help fix it, and then you get naked and I take pictures of that body part and then I usually also pinch it…AHHH!!

I genuinely feel that one of my strengths is making people feel at ease with me, and it brings me joy when I can make something as scary as this into something at least somewhat pleasant and life-affirming.

Thank you, as always, for coming along on this adventure! I am extremely open to ideas, questions, feedback, all of it - you can reply to this email or you can DM me on any of the internet places :)

Talk soon,
LM

P.S! I am really loving podcasting more and more - if you haven’t listened to Cut & Tell yet, give it a try and lmk what you think!! Recent topics include: what I bought to prep for my first day of work, advice on specialty selection for med students, and an episode on my very first day.

P.P.S! I am continuing to build out my website!! Would love it if you have any ideas or suggestions on how to make it better - I got a spontaneous facebook comment from somebody who noticed it’s actually real and not AI/marketing-team-nonsense and I was SO PROUD!!!

Hey y’all,

Can you believe it’s finally here?! The first day of my real plastic surgeon job is MONDAY. I assume I will mostly just be hanging around with no patients to see since that’s how it goes in private practice, but I am extremely excited nonetheless!!

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Below I have a bunch of links to what I’ve been doing and writing since my last newsletter, but before I get to that, if you or anybody you know has been thinking about a breast lift/reduction/implant, a tummy tuck, a little lipo, an upper bleph, a labiaplasty, gynecomastia surgery, honestly anything in the aesthetic plastic surgery space, please tell them about me!! Here’s my shiny new website, which includes a consult request form that, at least for the moment, just goes directly to my email inbox.

I’ve really enjoyed this magical liminal space between residency and practice, though more than anything, it’s just affirmed that I am a person who likes to keep busy. I did take a few “bed rot” days where I just napped and read or watched tv and didn’t talk to anybody and honestly I think that was good for me…to be forced to slow down and reduce the total input going into my brain.

Then I had a TRANSCENDENT week of vacation in Savannah and Jekyll Island, GA, where I got to watch the sun rise out of the sea every morning just a few steps from my hotel room, and frolicked (there’s just no other word for it) in the hot-tub-warm surf. There’s just something about that part of the country: the marshes, the live oak trees, the whole Southern Gothic vibe of it all that brings me a deep, soul-replinishing joy.

Flannery O’Connor is, after all, one of my favorite authors. So it seems only fitting that newly-un-busied me would go to Savannah and decide to write a book. It’s still very much in its nascent stages, but I think I have something to say and that a book is the way to say it. I promise more details once (if) I get things formally off the ground!

Speaking of feeling like I have things I need to say, I know I’ve managed to rub some people the wrong way with my most recent essays (below). But what I’ve found in conversations with some of the folk who reacted most negatively is that they don’t necessarily disagree with the points i’m making…they take issue with the fact that I’m saying these things publicly. I’m airing the dirty laundry. I’m saying the quiet part out loud.

I don’t think that’s fair. We need major change in our medical education system, and in our healthcare system in general, and it’s not going to happen through everybody keeping their head down and grinding it out. Of course there are many amazing physicians working within the system to try to make things better. I do not intend to speak ill of them in any form. But we need people (like me!) working from the outside too.

What’s the point, after all, of having a platform if you’re not going to use it to stand up for what you believe in? And I am in a rare position to be able to speak openly about the problems in medical education and health policy because I am going into private practice (plus, I have a background in health policy).

I don’t have to worry about what my new department head will think, or if my new hospital has a strict social media policy or not. It’s not without risk, of course, and people have made me acutely aware of that. But I heard from so many people—not people who followed me on insta because of my silly videos, but more likely got forwarded my essays by a scandalized attending somewhere—who told me privately that they had shared some of the same experiences as me, and were glad somebody was willing to say it out loud.

And so I will carry on! And I’m SO very grateful to the Hippocratic Collective for believing in me and supporting me, particularly on the days I was tired of fighting.

And so if you haven’t read them yet, here’s the goods:

• Back in my day: a resident’s retort : all of the ammo you need if you ever feel like (at least in your imagination) going toe-to-toe with that curmudgeonly surgeon who says that training today isn’t what it used to be

• You can’t eat prestige: but people will try to feed you with it nonetheless. Reflections on my turn away from a life in academics.

• Crying in the bathroom: (this is what probably got the most attention from my attendings) I really wrote this for me to look back on—to put a stake in the ground against the inevitable wave of residency amnesia that I know is coming.

• The Pitt on why residents can’t have boundaries: it’s a zero-sum game, yall!

If you read this far, thank you so much for your support and for following along with all of my adventures!!!! I always love hearing from my Substack readers, you can reply to this email, or you can DM me on Instagram.

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Hey y’all!

This past Saturday, I graduated from plastic surgery residency at the University of Pennsylvania. We celebrated with a black tie event at the Mutter Museum, where each graduate gave a speech. Here’s mine.

Thank you for following along on my residency adventure, and I can’t wait to tell you more about what comes next!!

Stay tuned :)

- Liz

The first time I ever saw a surgery, I was 8 years old. My sister, who was 5 or 6, had busted her chin open on the playground. She was bleeding, she was crying, there was some SubQ fat hanging out, which was gross but in kind of a cool way. My mom scooped us up, drove us to the hospital, and I had the opportunity, at this very young age, to watch an incredible, mildly terrifying surgeon sew her back up.

That surgeon was my mom. She is here today (hi Mom!) but there’s something important I left out of this story, which is that she is a doctor of veterinary medicine. That “hospital” was her animal hospital. And my mom is on the record as hating surgery.

Though it took me awhile to find my way to the OR, looking back, there probably were signs that I was destined to be a surgeon. Those signs were just pointing at a golden retriever.

Greenville, South Carolina, where I’m from, was a much smaller town when I was growing up than it is now. It was famous in those days for two things: an Umbro shorts factory (those are cool again, by the way), and a very successful religious fundamentalist cult. My mother ran her own practice my entire childhood…she built that thing herself, and she raised me in it…and she is the person I credit with giving me the characteristics that have landed me here today, giving a speech in front of the top plastic surgery program in the country.

Above the Mason-Dixon line.

Despite the classic trope of the millennial participation trophy, my mother taught me that I was NOT special…and that the only way to be special was to work hard, to maintain your independence, and to quote my favorite line of hers, to “never let the turkeys get you down.”

When I first interviewed at Penn, I was sure I didn’t have a chance to get into a program like this. So much so that I even convinced my husband, Greg, that it wasn’t gonna happen, though he is usually wise to my self-deprecating ways.

I didn’t do an away rotation here, I had no connections other than that i liked the show It’s Always Sunny in Philadelphia, but when I came up to interview I just felt this spark of, “oh, so this is what a truly great program looks like.”

Penn is a legendary place. I won’t rehash all the ways, because If you’re here, you know. But there’s something special about this program that I don’t think gets talked about as much. And given where I’m from , it’s something that’s important to me.

Penn doesn’t try to make all of its residents the same. It’s a place that recognizes the value of what makes us different, and wants us to keep those parts of ourselves alive and well alongside our rigorous training.

It’s a place with a long history of independent thinkers, pioneers, and leaders, and that’s what Penn encourages us to be as well.

There’s another program, which I won’t name, where I interviewed for residency and as sometimes happens, I got to hear some of the details of their assessment come back to me through the plastic surgery grape vine.

They said that while I was very impressive, they were worried, given all of my experience in policy world and my assertive personality, that they wouldn’t be able to “break” me.

Penn obviously saw things differently, and in fact came to celebrate those parts of my personality that may have scared others off. To quote one of my very favorite evaluations–and these are anonymous, so I don’t actually know who said it or if it was meant as a compliment:

“Liz has good clinical judgment and is not afraid to share her opinion, even when it contrasts with the current plan.”

I had the privilege last week of attending the celebration of life for Dr. Linton Whittaker, and I also had the opportunity to meet him several times during my training, including at one of Dr. Serletti’s famous call-team Christmas dinners. Dr. Whitaker had an incredible impact on our field, largely because he was willing to challenge the status quo if he thought it would be better for patients. He also valued surgeons working together rather than in competition, exemplified by his founding of the CHA. My hope for my career is that I can carry that energy forward.

So, to all of our faculty, thank you for teaching me. Dr. Serletti and Dr. Fosnot, Drs. Shakir and Azoury - who I had the great pleasure of both training with as co-residents and now as my attendings - Dr. Swanson my mentor, Dr. Kanchwala my PennMicro buddy, Dr. Rose my private practice princess inspo, and Dr. Chang the tiger-dad that I never knew I needed. Each and every one of the Penn Plastic Surgery faculty will live rent-free in my head whenever I’m in the operating room. Thank you for trusting me.

And thank you in advance for answering my neurotic texts now that the training wheels are finally coming off. I know I’m ready. But it means everything to know you’re still in my corner.

And to my fellow co-residents: My mom taught me that if you have two pet rabbits and you want them to get along instantly, you can put them both in an empty bath tub, and something about this strange, foreign environment with no apparent route for escape…it freaks them out so much that it forces them to get along. To trauma-bond. All y’all are my fellow bath bunnies.

Residency is hard. Long. Intense. At times, overwhelming. But sometimes, you do get to go home, and then your bike chain breaks on the South Street Bridge at midnight and you decide to just walk back to the hospital and sleep in the office because you’ll probably be called back soon enough anyway.

I leave here with the closest friendships I’ve ever had in my life (Hi Carrie, newly minted Chief Resident), my boys as I will forever call them: Will, Dustin, and Sharbel, and a long legacy of strong men and women, coming up behind me.

And now, to my husband Greg.

Greg. My momma raised me to be an independent woman who doesn’t need to rely on any man.

But in that respect, I am an abject failure.

And the most amazing thing is that Greg has not only supported ME through residency, he’s supported a lot of YOU through residency. At the very least, I know that he has fed every resident here at least once, and for a couple of you he has been a regular source of sustenance. And not just any sustenance: we are talking about some quality cooking. From CIA—Central Intelligence Agency, you might say, to CIA, Culinary Institute of America.

I also can’t leave this podium here without thanking Greg’s parents, Carol and Richard: thank you for your unconditional love and confidence in me. You all should know that while I rely on Greg now, I relied on Carol and Richard in med school, especially the year Greg was in Afghanistan.

And then lastly, I’d like to take this moment to remind you, Greg, that this was all your idea. I was perfectly happy to carry on as a science writer or some middling policy wonk somewhere, but YOU saw something in me that I didn’t see in myself back then, and I can say with complete confidence that I’d never have gotten here without you. And while I know there are challenges ahead, I also know that we’ll fight the turkeys together.

And with that, thank you, Penn Plastic Surgery, for everything. I’ll see you around Philly.

P.S. My books are open starting July 27th and friends and family rates are available, so please inquire!

Hey y’all -

Forty-nine more days til graduation and things. Are. Happening!

Last week I wrote my first Progress Note for the Hippocratic Collective. Residents: Know Your Worth is basically my primal scream into the #MedEd void. It’s a piece of writing that scared me, but one of the things about being a chief resident is realizing that basically your whole life up to this point has been an exercise in meeting expectations, achieving the next milestone, and fighting for every last gold star and glowing eval. But if you’re never hitting any friction, you’re probably not doing anything real. Surgical education is something I’m passionate about, so it ought to be something I’m making people feel uncomfortable about from time to time.

The first episode of my new podcast, Cut & Tell, premiered this week too!! I’ve been working on this behind the scenes with the HC for a couple months, and it’s been more challenging than I expected to adjust to the format. Given that I’ve already vanquished my compunctions and modesty through exposure therapy (aka by putting videos of myself saying things and even sometimes wearing costumes on the Internet all the time), I thought podcasting would be nbd. But thanks to my producer Frances Mei (and co-producer Louis the Cat, of course) I’m learning to relax into the longer, looser format. To resist the urge to cut every filler word. To let a moment land. It’s a different kind of vulnerability that I know will take me some time to master.

Last week I also got to be part of a photo shoot for the amazing practice I’m joining in July, Bloom Aesthetics Group! My neck hurts from doing that “make like a pterodactyl and then drop your chin” thing they make you do to get your face right for pictures, but I must admit it seems to work, because I’ve truly never been more satisfied with photos of myself.

We’re also starting to think through the logistics of bringing breast and body surgery into a facial plastics practice. For example, people don’t really get naked when you’re operating above the clavicle?? We’re going to need full length mirrors! Robes! Underwear! And I’m STILL hemming and hawing about what particular camera setup I should get for clinical pictures (I’m leaning toward a Canon EOS R6 Mark II Mirrorless with a RF 50 mm f/1.8 STM lens).

Talk soon — Liz

Hey y’all -

This whole internet thing I’ve been doing is a one-woman show (well, me and my producer, Louis the Cat). And despite surgeons’ reputation for lone-wolfing it, I am not and have never been a loner.

When I started posting on Instagram a few years ago, it was controversial in my world. The message I got from people around me in my lil residency bubble was that I was being reckless. That I was inviting trouble. That this could blow up in my face and get internet-shrapnel into everybody around me too.

At the time I wanted to look at these people and say, but y’all, it’s me, remember? I’m a conscientious, hard-working resident who’s been slinging deep dermals alongside you for years and I just want to post study tips and MedEd explainers and pictures of hospital snacks. I’m a doctor. Do you really think I’m not responsible enough to do this?

I kept going, but I did everything I could to keep myself apart. Solo by design, but not by personality. But now, with residency coming to an end, I’m ready for something different.

I’m joining the Hippocratic Collective. I’ve been getting to know their team for a while now, and I believe at root we’re motivated by the same things. We think doctors (especially residents!) deserve better, and that the system we’re working within now is ripe for disruption.

They like that I’m, to borrow a phrase, “being reckless” (if by reckless you mean willing to step out of line for something I care about).

I’m excited for this partnership to unfold. To begin, I am going to be publishing my more in-depth articles and explainers as Progress Notes. I’m also starting a podcast on their network (look out for updates soon!!).

I love Substack, but it’s not indexed on Google and asks people to log in. Therefore, it honestly isn’t the right home for the longer-form guides, explainers, and think pieces that I think are actually the most valuable content I make.

I’m going to keep writing here, but expect a more personal flavor. Think “letters from the frontlines” of my first year in practice, plus I’ll keep you updated on what I’m writing, doing, and recommending these days (plus occasional photos of Louis hard at work).

If you made it this far, THANK YOU for your support and for coming along with me on all of my adventures. I’m excited for what’s next!! And if you haven’t already, please consider adding the Hippocratic Collective to your media rotation. They’re starting a movement. I’m on board, and I think you should be too.

History is written by the victors. Or to put it in medical terms, history suffers from selection bias.

We hear from the people who succeed. They are the ones who share their stories, and we strivers seek them out.

But these stories are boring! And their lessons are all the same.

Work hard. Persevere. Adapt. And ~voila~ you can be just like me.

But that’s not really true, is it? A lot of people do all the right things, and it still doesn’t work out. Those stories are harder to come by, not to mention harder to hear, but THOSE are the stories we actually need.

For residency, that story is finally being told. It’s called Surgeon on the Edge by Frances Mei Hardin and it’s the #1 book I now recommend for anybody who wants to understand medical training today.

But first! Stop telling med students to read House of God

We treat House of God as the canonical residency memoir. It’s dark, it’s cynical, it’s supposedly “honest” about how brutal training is.

But y’all. HOUSE OF GOD IS A SATIRE.

It’s supposed to make us see what’s wrong with medical training, not what to accept as normal. And somewhere along the way we forgot that distinction. The satire has become reality, and worse, we’ve accepted it as inevitable.

It was also written almost 50 years ago about a health system that bears little resemblance to our system today.

If this is the book we’re handing to future doctors, this is what we’re telling them: expect to become numb to suffering. Expect to be treated poorly, and to ultimately perpetuate that poor treatment upon those coming up behind you. Expect that nothing will change.

We should want them to read something different.

Read Something That Scares You For the Right Reasons

Frances Mei Hardin did everything right.

She proved she had all of that stuff they say you need—grit, perseverance, hard work, determination, you name it—and she saw it all the way through to become a board-effing-certified ENT.

And then she left.

Her book—and I refuse to spoil it—shows you why.

She’s the canary in the proverbial coal mine for residency in the US, and we need to listen to her.

It’s clear from the Internet’s reaction to Frances Mei that some people think what happened to her is contagious. Like even hearing about somebody leaving medicine might infect them with doubt.

If that’s you, it’s all the more reason you NEED to read it.

If you’ve become unliterate—a term I made up for people who know how to read but do not regularly read books now that nobody is making them—let me also say that Surgeon on the Edge is brilliantly written. It’s fast-paced, honest, clever, and devastating. It’s written with an intensity and economy of motion that only a surgeon could muster. You can finish it in a day and a half.

Next time a bright student asks for a book recommendation, give them this story of a surgeon with the courage to show you both sides: she is flawed; the system is flawed. And the real key to residency is to learn the difference.

Link: Surgeon on the Edge

If you like hearing from me and want to support the mental and emotional wellbeing of a resident who is thisclose to graduation, please subscribe and share this post with a colleague or friend! Every new subscriber brings me a bright lil moment of joy like that feeling when you come across an unexpected sunny window in a hospital stairwell.

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I have spent thousands of dollars on Q banks and test prep resources from the SAT straight through to the USMLE. But I will never spend money on one again. The era of Big Test Prep is over, and good riddance!

Let me show you how I started building my own study resources—including a Q bank—and how you can get started building too.

But first! A rant

Think about how much of your life you have spent making internet accounts and trying to log into things. You can’t order a sandwich or watch a 30 second video or pay at the parking garage anymore without giving up your personal information, providing evidence that you’re not a robot (which is getting harder??), and opting into some form of marketing.

DID YOU KNOW THAT IT DOESN’T HAVE TO BE THAT WAY 🤯

They are doing that to extract your information so they can market to you more precisely.

So for the couple of things I’ve made that I reference here, I just want you to notice that you don’t have to make an account. Apparently all of the information you need to use websites like this can be stored locally on your browser/device, without the friction of account management.

(That being said…please subscribe to my free, human-written Substack. Every time somebody subscribes I get back one of the soul horcruxes that residency has taken from me and stashed all around the hospital. Tell your friends!)

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Let’s get to it.

Which AI tools I’m using

I’ve spent a fair amount of time messing around with the menu of AI options, and to me, Claude is like that super-smart, motivated, efficient intern that you just know is going to be a better doctor than you someday. That’s who I want working for me, so that’s my main hub.

I have a $20 per month plan, and work with Claude in two forms: the regular chat mode that you’re probably accustomed to from ChatGPT, and then Claude Code, which is the special Claude tool that lets you build websites and such.

Open Evidence (free dollars if you have an NPI) is way better than Claude in terms of depth, reliability and let’s say “realness” of clinical knowledge, but it is not capable of the more expansive knowledge work that I’m doing with Claude. For example, I can ask Open Evidence to write 1 or 2 MCQs on a specific topic, and they are EXCELLENT, but when I asked for 10 it kept glitching out because that’s just not what it’s designed to do.

Claude is not really in the image game. When I asked Claude to draw a finger, it drew a weird stick figure and then when I asked it to make a better one it thought for like 15 minutes and then told me I had met my limit for the day. So when I really want an image of something, I go to ChatGPT and it does a pretty good job (I haven’t fully explored AI-image generation world, so let’s just say that’s out of scope for this)

My advice for talking to AI

Don't ask something once, get a bad answer, and declare "AI is dumb!" while you go back to mindlessly scrolling. Be curious. Be persistent. Iterate!

If you're not getting what you want: go meta (explain why the response isn’t right and ask what you're missing), switch tools (different AIs are good at different things), combine forces (feed output from one AI into another), or check Reddit (there's probably a hyper-specific human community that's already solved your problem).

The first thing I made: a game

I told Claude I wanted to make a hand anatomy game with a simple interactive component. We went back and forth on topic, format, and aesthetic. Then Claude walked me through all the setup I needed to put something on the internet.

What’s weird: I now have (free) GitHub and Vercel accounts and NO IDEA what either of those things are. I guess they turn code into the Internet?

Meet the Hand Nerd Detector. It’s a matching game for hand anatomy…one of those topics I have to review every year because I always forget a couple.

It’s simple and kind of dumb!

But the fact that I can make something like this feels like magic. Way more satisfying than staring at the same chart in my notes for the sixth year in a row.

Up next: a Q bank

The more specialized you get in training, the smaller the pool of people taking your exam, and the rarer (and more expensive) good study resources become. This annoyed me, so I set out to make my own thing.

PlasticsBank is a website I’m building with MCQs, flashcards, and tables for the plastics in-service exam/written boards. I gave Claude the publicly-available test outline and described what I wanted. The resulting website is very much a work in progress as I move through studying different topics for myself, and I am continuing to tweak it and mess around with features and functionality.

Some of the questions Claude writes are good! And some of them are weird or just wrong. But honestly you learn a ton from looking at a question that might be wrong because it highlights whether you really know something or are just used to answering that kind of question. My dream is that other people in this very small world of plastic surgery trainees will try out the questions and give feedback, and then I’ll use that feedback to make the questions better and better.

A side-note on aesthetics: you can describe the look you want or show Claude examples of what you like. To me, this is probably THE most fun part. I asked for Windows95 vibes with anachronistic emojis. Claude got it on the first try.

The internet looks so boring these days! All minimalist sans-serif sameness. I hope that we’re entering a new era of chaotic, colorful, unserious design.

What’s next?

I’m old enough to have learned some lite HTML when i was in high school in order to customize my MySpace page. The internet was fun back then! It was colorful and chaotic and weird and you could make your own wallpaper.

This Claude Code thing reminds me of that.

AI removes the barrier of technical expertise. Want to build an internet thing? Do it! Especially if you are a part of a niche community like plastics where commercial resources are sparse and overpriced, you should stop paying for stuff that’s mediocre. Seize the gears of the machine and make something specific and fun and weird instead.

Right now I think a lot of people feel like AI is making the internet LESS human. But based on this, I think it could go the other way.

Have you tried making things with AI?? Tell me about it, I’m curious!

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The point of going to residency is to get a job.

And not just any job: a really great, meaningful, real job that’s worth the 4 years of med school and 3-7 years of residency you put into it.

You've been assembling the career-version of an especially complicated Ikea cabinet for 7-10 years. You've had step-by-step instructions to follow, YouTube videos to watch, a customer service line to call. The problem is: you grabbed it off the warehouse shelf without really looking closely at the picture on the box. Now that all the pieces are finally coming together, you need to decide: is this even the right cabinet for me? Will this hold what I want it to hold? Does it tie the room together like I was imagining?

And unlike Ikea, there are no returns!!

But don’t panic. There’s always an Ikea Hack. And honestly, a lot of the Ikea hacks I’ve seen turn out better than the original.

I’m here to help you Ikea-hack the core existential crisis of residency.*

Enough with the metaphors. Let’s get to it.

This is not your mentors’ healthcare system

First, let’s be honest about the state of our industry. The healthcare environment has fundamentally changed, largely due to shifts in the financial structure of the system. I mean maybe you are going to be a small town primary care doctor with an independent practice where you make enough money to live well and pay off your loans? But probably not! If you work in academia, odds are you are going to have productivity incentives and other metrics that will drive your compensation, you’re not just going to be thinking smart thoughts during “protected academic time” in a cozy office somewhere. And if you want to go into private practice, you should know your industry is increasingly being devoured by private equity. And those guys are not our friends!

No matter where you go, doctors have less autonomy (with the same liability), less money, and more clicky boxes to click than prior generations of graduating residents have faced in the past.

I don’t want to be all doom and gloom here, but... it’s a little gloomy and doomy out there for the American healthcare system.

I don't say this to depress you. I say this because all of this happened pretty fast, and it’s the rationale behind the first lesson I want you to take from this:

When they picked their paths, the landscape was different. It’s a trap (an example of what psychologists call the halo effect) that we want to trust the people we trust about clinical medicine to also be right about career advice. But your mentors’ clinical wisdom comes from seeing thousands of patients. Their career advice? That's often based on a sample size of just one—their own path—which was taken under completely different conditions.

You need a much bigger sample size than that. Which leads me to point two:

Residency is your whole world right now, but all you really know is one institution. One set of faculty who all have the same sort of job. One culture. One city. The variation in doctor jobs is much much much greater than you think. It’s tempting to want to look at the people you work with and say: which of these people’s careers do I want? But if you do that, you are limiting yourself. Maybe ultimately you WILL want to model your career on that of your mentor. But there’s no harm in a little thought experiment Rumspringa.

Talk to people outside your program. Go to a conference and network with people outside of your residency bubble. Find somebody in your city who has an interesting job that seems cool to you and ask if you can grab a coffee. Ask them why they chose that path, whether it matched their expectations, and what they wish they’d known.

Reach out to recent graduates from your program. Look at the list of people who finished in the last 3-4 years and contact the ones who did the kind of thing you’re thinking about doing. They’re close enough to remember what the decision-making process felt like, and far enough out to have some perspective on how it actually worked out.

De-categorize the jobs. A lot of people try to segregate the physician job market into different buckets: academia, hospital-based, private practice, etc. In reality, it’s a continuum. It’s not even just a continuum: it’s a galaxy of options that differ from each other along at least a dozen criteria. There are academic jobs that feel like private practice. There are private practices that are essentially hospital employment with a different contract structure. There’s part time clinical jobs you can do while you’re building your solo thing. There’s academic jobs where you don’t have to do research and private practice jobs where you do. Don’t let people put you in a box before you have a look around.

The goal here isn’t to dissuade you from following the path of your academic mentors. The goal is to make an informed decision about your future and walk into it with your eyes open.

To that end, I give you point 3:

What is actually going to make you feel good about your job? There’s a whole world of research on this you can explore for yourself, but this is what I think is high-yield:

Money matters, but only up to a point. Studies consistently show that once you’re paid fairly enough that money isn’t a constant stressor (the vast majority of doctor jobs should meet this bar), other, non-compensation factors matter much more for whether you’re happy at work or not. The golden handcuffs are going to be super appealing at the end of residency, but there are plenty of people out there with high salaries who hate their jobs. Check those handcuffs out, maybe try them on. But don’t fool yourself about what you’re getting into.

Autonomy and control matter. Research shows that having control over what you do, when you do it, and how you do it is a major drivers of job satisfaction. Think about what kind of autonomy matters to you. Do you need to control everything, down to the office voicemail? You might struggle in a big bureaucracy. Or maybe autonomy for you is more about having the freedom to travel for conferences knowing someone’s always around the office who can help out in a pinch. That’s a different kind of autonomy—the kind you might get from working in a larger organization.

Who you work with matters just as much as what you’re doing. This shows up over and over in job satisfaction research: having good colleagues and feeling appreciated are bigger drivers of happiness than the actual content of the work. Liking your team, feeling valued, feeling like you’re growing: these things matter too. Think about your own set point for these factors and what you want your work community to look like.

(If you want to go deeper on this, google Daniel Pink and watch his videos about motivation or read his book Drive.)

One of the advantages of still being in residency is that you have time to run some experiments on yourself. Pick a version of your future career and commit to it in your head for a few weeks. If it would involve additional training or research, start doing those things. See how it feels on a good day and on a bad day.

We have a tendency to focus on just one specific image when we imagine a career: doing that one really cool case, sitting in that particular office. You need to think about the Tuesdays. About what a bad day looks like. How you’re ACTUALLY going to be spending your work hours

Talk about it with your friends and mentors. Don’t be afraid to embrace it and to change your mind later. Do this early, try it a few different times, and you’ll have much more insight when it’s time to start looking for jobs.

And now it’s time for your homework. This is the hard part, because nobody else can figure it out for you, and to make matters worse, you should know that this is one of those areas where we are all very good at fooling ourselves. Before you can make good decisions about your career, you have to be honest with yourself about what you actually want your life to look like.

Not what you think you should want.

Not what would impress your parents or your mentor or your high school bully.

What you actually want.

Some questions to sit with:

What kind of daily life do you want? Look at your attendings’ lives who have careers similar to what you’re considering. Does that actually look appealing to you? Do they seem happy and if so why/why not? Ask them what they like and dislike about their jobs, and what they wish they could spend more/less time on. Ask them what their first year looked like. Is this actually a path you want to follow?

What cases do you actually like doing? Be careful here: don’t just think about the rare, exciting cases. Think about the bread-and-butter work that’s going to make up 80% of your days. Are you going to like that? Do you like doing a few big cases or a lot of small cases? What kind of patients do you think you connect with best?

What are you getting paid to DO? I mean what incentives are you going to be motivated by and working toward? What are you actually going to be spending all of the minutes and hours of your work time on? Advancement in academia often depends on research output: have you been doing research this whole time because you had to or do you actually like it? Do you actually like working with learners or did you just have fun that one time you taught that one med student something? Does a productivity incentive motivate you or just annoy you?

Are you chasing prestige? If so, have you examined why that matters to you? That might sound harsh, but it’s worth asking. You’re at the end of the trail here. There’s no next thing you need grades or research or extracurriculars for. This is it.

What would make you feel like you made the right choice? In five years, when you’re settled into your job, what would need to be true for you to feel satisfied with your decision?

Write this stuff down. Even if what you land on is “I want to make as much money as possible to pay off my loans as fast as I can, and even if the culture and location sucks I can deal with it for a few years” - that’s fine! That’s useful information! That tells you something about what to optimize for and what you’re willing to accept and forces you to look at the tradeoffs you’re willing to accept.

The people who are most satisfied with their choices tend to be the ones who were clear about their values and priorities before they started evaluating options. Otherwise, you end up making decisions based on whatever seems most salient in the moment or whoever makes the most persuasive pitch. Don’t let residency burnout or first-year-fear drive you down a path that doesn’t fit your values, and don’t just grab the shiniest ticket out.

While this decision point is a big deal and you should take it seriously, the reality is you can’t predict the future. You aren’t going to be able to game out exactly what will happen in your first job/career trajectory and how you’ll feel about it. And that’s ok! You are changing and growing over time and the system is doing the same under your feet. People will tell you that if you go through one door, others will be closed forever. That’s simply not true.

*I’m no career-guidance expert, but I am a career changer. I’ve worked as a professional musician, in retail, in startups, nonprofits, politics, and academia. I’m graduating in 6 months, so I haven’t actually had a real doctor job yet (though I am PUMPED to be joining Bloom Aesthetics Group, July 2026!!!!! Sign up here for updates). But I know from residency that sometimes the best advice comes from the people just one or two steps ahead.

I’m in my sixth (6th!) year of residency, which I think qualifies me to have an opinion on what makes a good gift for the resident or soon-to-be resident in your life.

First off, here are good gift options that you probably already thought of so we can just move past them: Stoggles eye protection, Yeti mugs/Stanley cups, compression socks, nice pens, and bluetooth speakers. All great! But you don’t need me to explain.

Read on for my residency gift guide, which I am dividing into two broad categories: (1) practical gifts that are actually related to and useful for a resident’s professional life, and (2) things to nurture the humanness of your resident when they are outside the hospital.

Part 1: Practical Gifts

A call kit: get a high-quality toiletries bag (like I am lusting after this one) and fill it with a bunch of little treats to bring your resident joy or comfort during an overnight shift. Some nice mini skincare products. Fuzzy socks. A phone charger. A few tabs of tylenol/motrin/tums (believe it or not we don’t have access to these at work!!). Some fancy candy or mints. Singles for the vending machine. Dry shampoo. Mini toothbrush/toothpaste. A lil eye mask for trying to nap in a room with those motion sensor hospital lights that you can’t turn off. Tweezers! This is practical in the extreme but who doesn’t love a present that’s full of other presents.

Portable phone charger: residency is not a desk job (like, most residents don’t have their own desk to sit at even if they wanted to). We rest in the halls, in the SNACK-Us, we grab a moment of quiet in a poorly lit stairwell, enjoy a nice long pee in an under-trafficked single restroom. Our phones die frequently and we are rarely prepared for it!

Since we’re being practical I think Anker makes durable and affordable electronic products of all kinds and that’s what I’ve used. I’d go for one of these mag ones in the cute light blue color, but there are of course trillions of options and even if they already have one they would definitely like to have another. Not special enough? Spring for this one that looks like a tin of anchovies, I would LOVE to pull this out of my pocket in the hospital.

Heated vest: full disclosure, I’ve only seen these on my anesthesia colleagues but damn do I envy them. Especially if your resident does night float, we all experience the dreaded cortisol dips and spikes that come with irregularly irregular sleep. Give your resident the gift of temperature regulation.

UberEats/GrubHub gift card: All but the elitest of meal preppers among us struggle to feed ourselves in an economical yet soul-satisfying way while in draining (this was a Freudian slip of “training” but I decided to leave it lol). Food delivery is our collective guilty pleasure. Don’t judge. Enable us.

Sunrise alarm clock: Depending on where your resident is in the country, they are probably spending 30-50 percent of the year waking up in the dark and coming home in the dark. That is not great! Some of my co-residents swear by these sunrise alarm clocks to help them feel a little better and calmer getting up in the morning. I don’t personally have one, but here’s some well-curated suggestions.

Open-ear headphones: Most of our lives in the hospital alternate between periods of frenzied activity and then weird indeterminate chunks of downtime that we mostly spend charting and waiting for stuff. It’s tempting, during these times, to disappear into one’s pocket sensory deprivation tank aka your noise-canceling headphones. There is truly nothing like that magical moment when all of the hospital sound just dissolves into nothing. BUT. We shouldn’t do that. It’s not really safe or appropriate. We need to remain aware of our surroundings. Enter: open ear headphones! I swear by these Shokz ones and use them every day for my commute, for listening to podcasts while traversing enormous hospital buildings, and yes, to catch some discrete music when I have a huge pile of charts to work through. They say these are for sports, but lemme just say, being durable and waterproof and high-impact tolerant are what we need in the hospital too.

Part 1.5: Practicality and luxury are a continuum

A bonus in-between category for the work-life balance integration crowd.

Mood lighting (to go!): one obvious choice for a resident gift is a portable speaker (great gift idea, but they probably already have one!). The speaker allows you to manage your space and your mood, and bring a little comfort to your charting time. The less obvious but I would argue just as impactful tool for mood management is lighting. The constant overhead fluorescents of the hospital are slowly driving us all mad. Overhead lighting is what I am most eager to escape at the end of a shift, and the first thing I do when I get home (sorry, husband!) is turn off all of the ceiling lights in favor of a few lamps. One of these lamps from the MoMA design store would be perfect (I’d pick the orange one) and it’s small enough you could even take it to the hospital with you for a slow call night. I also LOVE these orb-style lamps: they come in all kinds of sizes and types from lots of different sources, they are simple enough to fit with a wide range of decor, and will instantly change the mood of any space.

Part 2: Lifestyle Treats

Luxurious lounge wear: While it’s true that most of us wear pajamas to work every day, we still all come home and want to immediately change into different pajamas. This is an excellent gifting target. I would recommend going extremely luxe on the materials like this gorgeous and well-priced cashmere sweatshirt with matching sweatpants from Quince. Alternatively, I love the idea of a set of sweats that look polished so you feel more like a fancy work-from-home person than a couch troll. Something from Varley or a Halo wideleg set from Vuori. The Brand Naadam (which is actually what I have) makes cashmere sets for men too…don’t act like the men don’t want to be nestled in a finely spun weave of hair from the world’s softest goat.

Theragun: you already know about these…seems like a good gift for somebody who is holding tension in their shoulders (aka all of us). I have (aka my husband has) a mini one and I love it.

Fancy drinking vessels: There’s nothing that makes me feel more like a grown up than drinking out of a nice container. Leave the mini soda cans, the styrofoam cups with bendy straws, and the sensible waterbottles at work and embrace drinking your home beverages out of something beautiful and breakable without any kind of waterproof lid. My favorite source is CB2: you literally cannot go wrong with anything on this page. My latest obsession are these Zero Japan coffee mugs that I bought in my favorite color (orange). I also have a collection of real nice vintage bar glasses and some colorful gold-rimmed coupes (the fanciest of fancy drinking vessels), so you could even thrift something for this one.

Special condiments: this is a category that I honestly did not appreciate before I became a resident. Having never made boxed mac and cheese in my life before intern year it is now constantly stocked in my house as an emergency backup meal. These are hard times! But I’ve learned that with a few magical condiments on hand, you can transform even the grimmest bowl of sad pasta or end-of-the-weak meal prepped beans and rice into something to spark joy. The king of this category—the magical fairy dust that livens up literally anything with a crack of sunshine—is Maldon Salt, and it comes in pretty tubs making it highly giftable, (especially if paired with a charming salt pig). I also love a high-quality, intensely flavorful finishing olive oil like Graza on everything from pasta to eggs to toast. My personal favorite condiment right now is an intense lemon oil that came in a tiny tin that a friend brought me back from Italy so I can’t give you a link to it. I also have a stash of interesting vinegars/soy sauces/crispy toppings and I-don’t-know-whats from our local asian grocery store, which I use to level up one of my favorite weeknight meals, “rice with stuff on it.” You cant go wrong with the spice mixes from Burlap and Barrel. Honestly though just go to that cute lil cooking store in your neighborhood and buy that fancy aged balsamic, that tube of multi-colored peppercorns, the bougier the better!

That’s it! Have you given or received an excellent resident gift??? Please tell me about it I’m very curious, either comment here or send me a DM on any of that platforms :)

Not to be a grinch, but as a lil coda I’d like to address what’s NOT a good residency gift: anything cutesy celebrating doctory-ness. I’m talking dish towels with EKG tracings on them, signs or mugs that say “the doctor is in!,” whatever a stethoscope charm is (??) really anything that comes up when you google “gifts for residents.” Remember that residents are grown-ass adults, most of them nearly at or recently past the age of 30, working around 80 hours a week for less than minimum wage. It’s just not that cute! Also be careful of any gift that creates a commitment…a gift card to a massage place that is hard to schedule at, a weekend getaway, a cooking class. We want these things, but our capacity for planning is limited <3

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I started posting on social media for my own selfish ends. I was thinking about a career in private practice, and I thought building an Instagram following would be a safe(ish) way to cut my teeth in self promotion and personal branding while I was still in residency. But what I ended up learning is much bigger than me, and something I think every doctor out there needs to know.

Hear me out, and please send to the doctors in your life: there is a crisis of trust in American medicine, and social media is part of the solution.

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Doctors are no longer driving the conversation

Consider these statistics:

• 96% of people with internet access use social media, and they use it for 2 hours every day on average. While we all have that friend who “doesn’t do social media,” just know that friend is in a very small global minority.

• 54% of Americans use social media for news. Compare that to just 65 percent who are getting news from reputable news websites and apps. The walls that used to separate different kinds and quality-levels of information have all come down: information just flows directly at your eyeballs without any sourcing or context.

• 38% of adults aged 18-34 report having ignored a doctor's guidance in favor of information from social media, up from 26% the year prior. 45% believe the average person who has done their research can know as much about health as a doctor. 60% report regretting a health decision they made based on bad information from the internet

What’s going on here? Why are people choosing to seek their health information from social media over their own doctors? Why aren’t people checking the credentials of the people they follow online, or looking to medical journals for high-quality health information?

If you go one layer deeper, you’ll see that these statistics are symptoms of an underlying disease: people don’t trust doctors anymore.

Surveys show that trust in the healthcare system has plummeted. While 80% of people in 1975 reported having a high level of trust in the medical system, just 36% can say the same today. And while this is part of an overall decline in trust in a wide variety of institutions in our society, medicine has seen by far the largest effect.

So, who is making all of this trust-inspiring health information on social media? Take plastic surgery as an example: only 6% of plastic surgery content on social media comes from board-certified plastic surgeons. And while I couldn’t find a stat for this, I’d guess that among doctors, plastic surgeons are some of the MOST likely to be talking about their jobs on social media.

Social media is where people are learning about health and medicine. We, as doctors, need to be there to teach them.

If we’re not there, we are letting others shape what people think about us. We're losing the battle for patients’ trust by forfeit.

The New Rules of Trust

What’s happening here was predicted back in the 1970s by Nobel Prize-winning economist Herbert Simon, who was the first to theorize about the "attention economy.”

His theory states that when information is abundant, it loses its value. And what becomes valuable instead is that which consumes information: attention. In his own words: "A wealth of information creates a poverty of attention and a need to allocate that attention efficiently." Aka when talk is cheap, listening becomes expensive.

This represents a fundamental shift in how trust operates. Traditional medical authority relied on credentials, institutions, and formal expertise. Patients trusted doctors because they were doctors. But as information became democratized and institutions lost credibility, trust began flowing toward different qualities: personal connection, compelling communication, and perceived authenticity.

Social media amplifies this trend because it removes the traditional barriers between expert and audience. On Instagram or TikTok, a board-certified surgeon and a wellness influencer appear in the same feed, in the same format. The surgeon's credentials are de-emphasized. What matters more is their ability to connect and communicate.

Meeting Patients Where They Are

This creates both a challenge and an opportunity for medicine. The challenge is obvious: we're trained to be experts, not influencers (though we are trained as communicators, particularly in residency!). Medical education teaches us to be precise, cautious, and thorough: qualities that don't necessarily translate to viral content. Many of us are also constrained by institutional rules, professional liability concerns, and genuine uncertainty about how to navigate these platforms appropriately.

But to quote Jan Levinson, there are always a million reasons not to do something.

The opportunity here is huge—both for you as an individual doctor and as a representative of your field. People are actively seeking health information online, and they're often finding it from sources with far less expertise than we have. By engaging authentically on these platforms, and playing to our strengths—the knowledge and experience that we have spent our lives cultivating—we can provide patients with better information, and connect with them in the process.

My Experience

I’m still in training, so I positioned myself primarily as an educator for medical trainees, though I’ve heard similar reports from the practicing physicians I know who direct their content toward patients:

• Social media can help you build trust and rapport: when I meet people in person who follow me online, they feel like they already know me, and I know that they understand my perspective. We don’t have to start at square one.

• “Authenticity” = low production value. You don’t need anything fancy to start making social media content. In fact, the less polished you are, the more real you seem. And that’s a good thing these days!

• Social media is a form of leadership that operates outside traditional power structures, and as a result, it can benefit your career in unexpected ways, regardless of what type of job you have. This is especially true for academic careers, where demonstrating your national or international reputation is a key factor in many promotion decisions.

• Hating your voice, hating watching yourself, being bad at taking photos, not knowing how, these are all excuses. In fact, they are a great example of how we as doctors tend to be selectively agentic.

How can we reclaim trust in the attention economy?

To borrow a distasteful phrase, we need to flood the zone. No amount of hand-wringing or pearl-clutching inside our echo chambers is going to fix this. We need to be out there sharing what we know, even if it’s awkward, even if it’s embarrassing. Because that part, the painful part? THAT is what patients want to see. That we are humans. That we are imperfect. But that we are here because we want to help.

The Cost of Absence

Do you think anybody shows up to a doctor’s appointment these days without at least some light internet sleuthing beforehand? Patients are googling their symptoms. They are searching TikTok for possible diagnoses. They are also, by the way, searching the internet for YOU: the doctor they will eventually see.

And when you talk to them, whether or not you realize it, they are holding up everything you say against what they already learned for themselves. We’ve been playing defense for years. I don’t know anything about sports, but it’s time to seize that proverbial ball.

We’re never going back to the way things were before.

Our authority as doctors hasn’t been stolen from us, we have let it get taken away. We can go out there and take it back, or we can watch it go.

I know which option I'm choosing.

If you made it this far, thank you so much for reading!! This is an always-free monthly newsletter by me, an elder-millennial plastic surgery resident in Philadelphia. I have 378 subscribers as of today, please help me grow by sharing or subscribing below :)

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I don’t play much anymore, but all of my internal circuitry for learning was built and tested on 4 strings and some horsehair, and that’s never really gone away.

Throughout residency, I’ve puzzled over how becoming a surgeon is in many ways a similar challenge to becoming a violinist, but the two fields approach training in VERY different ways.

In music world, it’s “practice makes perfect.” In surgery world, it’s “see one, do one, teach one.” While both worlds have a heavy emphasis on reps (aka repetition) as the road to mastery, in music world you keep repping until you’re ready to go out there and perform. In surgery world, every rep is a performance.

I did a deep dive into the history of surgical training and the cognitive science of procedural learning to try to make sense of this. That research became an hour-long grand rounds talk, the juiciest bits of which I’ve highlighted below (and some I’ve already talked about on Insta).

I hope this sticks in your brain like it’s stuck in mine. Having a better “meta” understanding of what I’m doing has shaped how I approach residency, and helped me contextualize what’s wrong when things aren’t working.

Exceedingly brief history of why surgical training is the way it is

The Halsted Era (1880s-1930s): Dr. Halsted created the first surgical residency program. It was a Hunger Games vibe. Residents battled against one another for the attention of one man (Halsted himself) who decided when—if ever—they were ready to graduate. This was an inconsistent and unscalable system, but it is the primordial ooze from which our current system emerged.

The Churchill Model (1930s-1980s): Dr. Churchill turned this into something more structured and collegial. No more arbitrary rulings by your attending overlords: if you put in your time living (yes literally residing) in the hospital, you got to become a surgeon. This model started churning out a sustainable supply of surgeons with a moderately consistent skill set and knowledge base.

The ACGME Era (1980s-2010s): High-profile deaths linked to overworked, undertrained residents led to increased oversight by an alphabet soup of organizations. Graduating was still based on time-served, but now with much stricter rules, work hour limits, and standardized requirements.

Competency-Based Education (2010s-present): We are now in the midst of an evolution toward competency-based education: where measurements of performance increasingly guide the decision to graduate a resident, rather than time-served alone. We’re still in the early stages (particularly for plastics, which is a field where performance is extra-hard to measure), but this has the potential to make training better by focusing on the outcomes we actually care about, rather than time-served alone.

Ok I got the historical context, what about the science?

Learning to DO something is very different than learning information. If you’ve ever picked the wrong song at karaoke you know: just because you’ve listened to something a million times doesn’t mean it’s going to translate when you grab the mic.

Procedural learning in surgery, as in any field, requires a few key ingredients:

Working memory - This is the bottleneck of all learning, and an inherently limited resource. Your brain can only hold 7 plus or minus 2 active things at any one time. The problem is, doing surgery requires knowing more things than that. Additionally, your working memory capacity can be negatively affected by a wide variety of outside factors that are unfortunately inherent in surgical training: lack of sleep, distractions, stress, needing to pee, etc. And the only way that you can free up more spots in your working memory iiiiis….

Repetition - This is how stuff gets from your working memory into longterm storage, little by little freeing up space for more knowledge to make its way in through the working memory bottleneck. This is also essentially how we can justify the time-served model for surgical training: time-served is an approximate marker for number of reps.

Coaching - While common in other high performance fields from business to sports to aviation, coaching is still not a typical component of surgical training. We certainly do have mentorship, which covers some (but not all!) of what coaching means in other fields.

This is probably the area with the biggest potential for improving surgical training. One of the only randomized controlled trials I’ve seen in surgical education is about a coaching-based curriculum for a surgery rotation. Residents in the coaching model showed significant improvement in their operative skills. The residents in the traditional model showed no improvement at all.

Encoding - This is the active, on-purpose stuff that you do to try to help your brain store stuff better. Taking notes before and after cases. Reading. Reviewing. Asking questions. It’s hard and annoying but that’s just your brain reminding you that this stuff works.

The Three Stages of Skill Acquisition

Another useful way to think about this in surgery is through the classic Fitts and Posner model:

Cognitive Stage: Everything is new. You're relying on facts and conscious step-by-step thinking. Doing stuff is slow, you make mistakes, and it’s mentally exhausting. Think of medical-student-you using your whole brain to tie a knot.

Associative Stage: Steps start flowing together. You make fewer errors, your movements start to feel more fluid, but you’re still having to focus to get certain things right, and if you run into an unexpected problem, you feel totally lost. This is the intern who knows how to close an incision but sometimes their closure just looks bad and they can’t figure out why.

Autonomous Stage: True muscle memory. Your skill operates outside conscious awareness and does not require any working memory. You can close an incision automatically. You could probably do it in your sleep.

This progression requires reps over time. There's no shortcut. But again, that’s why time-served is not actually that terrible a proxy for surgical learning.

The irony of autonomy

Because the autonomous stage no longer involves any active recall, over time, you forget allllll of the facts and ideas that you used when you were first learning.

This is why learning from an attending can make you feel like an idiot: they are doing something that is simple for them, looks simple to you when you watch them do it, but in reality it’s a really complicated thing that they have forgotten the complexity of.

This phenomeneon leads to what’s called the “intermediate effect” in the psychology literature. Basically, the people best suited for teaching a task are often those who mastered it most recently. This is why trainee-to-trainee teaching is so powerful.

PennMicro: can we teach surgery like we teach music?

This meta-history-and-science rabbit hole led me to an experiment: working with one of my attendings (Dr. Suhail Kanchwala) who is also musical, we set out to see what it would look like to teach surgery like it’s music. We picked a discrete task that requires a distinct set of motor skills, and where opportunities for reps inside the OR are limited: sewing teeny-tiny blood vessels together (aka microvascular arterial anastomoses).

Like in music, we wanted to make reps “cheap,” aka something you could do easily anytime, anywhere with basic instruments (think: pens, paper, easily-liberated OR supplies). This also meant moving reps outside of the OR, and practicing for a few minutes every day, rather than in big, infrequent, multi-hour blocks as we typically do for surgical simulations.

We also wanted to break the complex process of sewing an anastomosis into a set of simple, discrete movements—sort of like scales or etudes in music—to allow trainees to focus in on building their muscle memory fundamentals.

We also incorporated coaching, since we have evidence that works: we had a few live practice sessions with trainees, and then we also had an ongoing text thread where we answered questions and assigned occasional “homework.”

The intermediate effect worked to my advantage: having recently learned these skills myself helped me bridge between my expert faculty attending (definitely in the autonomous phase) and our cognitive stage trainees.

This was just a small pilot project with a few trainees, but each of them was able to perform in the OR at a much higher level than is typical for their year of training. Trainees felt much better prepared for their first real microsurgery experiences, and that was reflected in faculty evaluations as well.

psst: if you want to see the videos yourself, they are all free online at www.pennmicro.org

Practicing surgeons

While the old dogs will talk your ears off back-in-my-daying about how easy we have it, the reality is that the way we train surgeons hasn't really changed that much in the last 100 years. Meanwhile, our health system has changed a LOT. Honestly, I'd say training now is probably more challenging because residents are expected to learn a larger, more complex set of skills with increased constraints on their time and autonomy.

The whole reason it's the "practice" of medicine is that it's not something you can just learn and then perform perfectly every time. You need reps. And just as in music, there's no number of reps that could ever make you perfect.

Small experiments like PennMicro show there's still room to grow. Time and resources will always be tight in medicine, and we have serious institutional inertia to contend with, but we owe it to our patients to keep making our training system better.

If you made it this far, thank you so much for reading!!! I have 299 subscribers to this monthly newsletter (free to sign up!) and I’m eager to keep growing - please share with a friend or two who you think might be into this particular brand of plastic surgery nerdiness.

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If you’ve been following me on Instagram, you know that I’m a plastic surgery resident in my final year of training, and lately I’ve been both looking back on the crazy road to get here and sharing what I’ve learned along the way.

I’m also looking ahead: starting to plan for my first year in practice, thinking about what I want my post-residency life to look like, where I want to be, and how I want to take care of my patients. It’s an exciting time! But also a little frightening and overwhelming. I feel ready, but also a little bit like Gollum emerging into the sunlight after my many, many years as a hospital troll.

1. So what’s the point of this

I’m here first and foremost to share what I’ve learned with the next generation of trainees coming up behind me. And I want to do that in an organized way that will be accessible to trainees in the future. While Instagram has been great for knowledge-snacks and advice-bites, I want this newsletter to be a way to synthesize those ingredients into more of a real education and mentorship meal. I want you to feel like you learned something, and that it was at least mildly amusing.

2. Who is this for

To start, this will probably be of most interest to those of you in the medical training pipeline. However, as this year goes on, I’m planning to pivot to include more content for a broader audience of people interested in understanding the chaotic world of aesthetic surgery and aging from the perspective of somebody like me: an elder-millennial who knows that there’s more to life than a smooth face and a flat stomach, but wants to look and feel good (and natural!) for as long as I possibly can anyway.

3. What to expect

My goal is to publish monthly (at least to start). Expect me in your inbox on a Friday, for some low-key learning and inspo as you head into your weekend, whether you’ve got a golden (aka a 2-day weekend) or a 24 hour call.

Topics on deck for my first few newsletters: Operating room manners class, staying sane and avoiding burnout in residency, interning like you mean it, study/note taking tips, and interview trail advice. I’ll also keep you updated on my own journey through my final year of training, and include some occasional product/reading recommendations. Honestly, I don’t know exactly where I’m going with this, but if y’all like it, I’ll keep it up!

4. Ok I’m in! What do I do now

Mash that subscribe button like you mean it! Better yet, subscribe and then share with the med student, resident, and/or plastic-surgery-curious people in your life. And if you have ideas for topics you want me to talk about or questions you want me to cover, add a comment or send me a message!

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