As described by those close to him, “Don't ask me how I know this…” was a common phrase used by Major John P. Pryor at the Hospital of the University of Pennsylvania as a mechanism for teaching from his own repertoire of experiences. Dr Pryor was killed on Christmas Day in Mosul, Iraq, in 2008 at the age of 42. It was his second tour of duty, having joined the US Army Reserve in the wake of 9/11. As Director of Trauma Service for the Hospital of the University of Pennsylvania, he was a leader in surgery, as well as a beloved father, husband, colleague, and mentor. In the narratives of his life described by his family and friends, he is perhaps remembered most by his willingness to lead by example. He taught from the wealth of his own training—both good and bad. He dared to be vulnerable and openly shared his experiences with colleagues and trainees. He was not afraid to talk about lessons learned from things gone awry and emphasized that every encounter, procedure, and day taking care of patients was an opportunity to grow and improve.
In 2008, several Vanderbilt University Medical Center (VUMC) surgical residents with an interest in teaching wanted to create a space to share their personal experiences of humanity and humility in training. After Dr Pryor's example, an annual session, entitled “Don't Ask Me How I Know This…” emerged. Though the session started in a surgery residency program, the concept of humility and the desire toward self-improvement throughout one's training and career are universal.
During “summer school” in July and August, surgical interns at VUMC spend every Friday morning listening to more senior residents discuss their approaches to topics ranging from common pages to averting crises in the ICU. Wide-eyed, the interns become acutely aware that they are no longer in the protected role of medical student. For these interns during the first few months of residency, when each page can be an immediate trigger for anxiety and trepidation, senior residents appear to possess an infinite amount of knowledge and poise when navigating the day. Every day has potential for missteps—typically caught by the watchful eyes of bedside nurses and chief residents. The interns try their best to impress their seemingly infallible chief residents, often feeling that they have failed at the close of the day. While these feelings of insecurity and imposter syndrome improve throughout the course of the intern year, for some they never completely go away.
Hence, on the last day of summer school, “Don't Ask Me How I Know This…” is held. The doors are closed. Medical students can listen, but they are briefed that what they are about to hear should be treated with sanctity and confidentiality. After spending 2 months dispensing knowledge in the lecture hall, ward, and operating room, these respected senior residents share their own vulnerable moments.
The session starts with the most senior person in the room and then progresses to the most junior, stopping at the last postgraduate year 2 resident. Interns listen: their feelings of being under the microscope lift. In turn, each resident shares how an experience has taught them an unforgettable lesson about how to better take care of our patients, ourselves, and each other. While humor is sometimes interjected, stories shared about loss, grief, error, and humility are often more meaningful in explaining how residents have transformed over the course of training. Interns, having spent 2 months idolizing senior residents and wondering when or how they will ever reach that skill and knowledge, realize that the education journey is a long one and that gaining experience takes patience and close attention. They are encouraged to accept themselves where they are, forgive themselves when needed, and rise the next day to remember and learn from the past.
Bestselling author Brené Brown writes extensively about the concept of vulnerability. She often refers to a speech by Theodore Roosevelt in which he said, “It is not the critic who counts…The credit belongs to the [person] who is actually in the arena.”1 It is not easy for physicians to discuss the scars of our past. As surgical residents, we stand in front of an auditorium on a weekly basis to dissect in detail the morbidities and mortalities we encounter in clinical practice. However, it requires even more courage to talk in a vulnerable manner about what we have learned and how we have learned it with our peers.
Research shows that, when adverse events happen, health care workers often turn to peers, and particularly to senior colleagues for emotional support and professional advice, to combat the isolation.2,3 Studies suggest that positive role models not only can affect resident responses to adverse events, but also can improve disclosures to patients.4,5 Thus, modeling vulnerability among peers may promote transparency in health care as well.
Physicians must be open to sharing their own experiences of shame, guilt, and loss as well as hearing those of others—this is imperative to sustaining a high-quality physician workforce within health care organizations over time.6 If we walk around in a cloud of silence and never process a tough outcome or lesson learned with each other, we cannot maintain productive, empathetic, and well-balanced clinicians. If an intern thinks an error made in the first month of their residency means that they are unfit for the profession, then we will promptly run out of physicians.
The “Don't Ask Me How I Know This…” session is designed to create a culture of safety and resiliency to save us and our future patients—to set the precedent early on that we are here to support one another through good and bad times. It is difficult to get up and talk about fallibilities to a group of young physicians who think you are infallible. But it is not fair to them or to us to be shrouded in anything but humility: we must share with one another the truth of our profession.
For programs that are considering a similar conference, we suggest that it be scheduled early in the academic year, but not so early as to incite intimidation or fear. We found 2 months after July 1 to be ideal, as newly minted physicians have usually experienced 2 different rotations and have had a variety of successes and challenges. It is important to classify the conference as a quality improvement conference and for attendees to fully adhere to both confidentiality and the framework of a positive learning environment free of reproach. Ground rules are distributed approximately 1 week prior to the conference for timely contemplation and to stress that the presenters should convey a sense of humility and respect, while avoiding humor as an inadvertent goal. Only select faculty are present in order to limit potential breaches of confidentiality and minimize fear of sharing. As noted above, presenters start with the most senior person in the room (usually the program director) through the last second-year resident. All residents are required to participate, but interns are there simply to listen and absorb. We have often formally recognized the most powerful stories at the end of the conference to reinforce the courage required to share.
Although “Don't Ask Me How I Know This…” began in August 2008 at VUMC, several months prior to Dr Pryor's death, the authors never got to share with Dr Pryor the fact that his words were affecting hundreds of residents in Nashville, Tennessee. However, his death turned the session into a more sacred experience. Starting in 2009, and now continuing a decade later, the story of Dr Pryor is shared at the initiation of each of these sessions as a reminder of what it means to lead by example. Through this exercise, we honor Dr Pryor's legacy, to help one another live, work, and thrive in this imperfect yet shared world.
The authors would like to thank all the Vanderbilt surgery residency alumni who were present in 2008 as surgery residents at the Residents as Teachers and Leaders conference (American College of Surgeons) and who founded the resident conference described in this article: Drs Felicitas Koller, Christina Bailey, Lesly Dossett, Kevin Sexton, Julia Shelton, and Kyla Terhune. The authors also would like to thank Dr John Pryor's wife, Dr Carmela Calvo, for reading and approving this manuscript. We acknowledge not just the loss of a surgeon and educator, but also the loss of a man who dearly loved his family.
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Competing Interests
This conference is a quality improvement conference and as such, the contents are confidential and privileged pursuant to the Patient Safety and Quality Improvement Act of 2005 (Public Law 109–41), T.C.A. 63-1-150 and 68-11-272 et seq., and has as one of its purposes to improve quality and safety of patient care.