Thank you, Tacey. I think that's incredibly well said. We got some great questions here from Rupesh, I believe I've asked both of these. The first and then the second or third to you, Brian, but the first was thoughts on how to collaborate outside of your institution. I think that's a really good question and I think it's a really important thing to do and pursue in your career. I'm going to touch a little bit on that in my talk, but I think it first starts with something Tacey mentioned was, what's your passion? Brian had mentioned this, but one of the things that is my passion is what we're doing here at this type of webinar. That's how I found other congenital cardiologists who were interested in the job search and the transition for first couple of years of attending, and that's how we formed that group. Really comes back to what are you passionate about and want to collaborate on. I think that's how you'll find other folks, because guaranteed if you have a passion, somebody else does as well. Bumping to you, Brian, he said, in your early career, how do you navigate letting fellows be more hands-on versus cautious about preventing mishaps? I'll let you do that one. That's a good one. You will find that that varies from attending to attending, from people who are out for their first year to people who are 20 or 30 years out. That's really variable. You can generally expect that if you are cathing with a junior attending, that they're not going to let you do as much as a senior attending. A lot of that has nothing to do with you. It has everything to do with the attending's level of confidence and the ability to get out of trouble if there's a problem. Again, there are personality differences too, and people teach in different ways. In some ways, it's good to just get it out in the open and ask that question. How do you teach? How do you approach training fellows? I talked a little about that in the talk. What's the ethos of the training program? How do you think about how you progress your fourth-year fellow? Just have that conversation so that it's out in the open. Everyone pretty much gets to the point they need to. I think if you look at the data from that Alan and his group put together, most places that are training, if you look at them, they're big academic programs. They have large volumes. Some of them have very niche specialized programs that you can learn from. But you will get good training, and you will get to the point where you feel comfortable. But do not suffer under the assumption that you will be ready to be an independent operator when you leave fellowship. If you think that, you're probably wrong. I think most people would say that you need five years to become a kind of a really, at a minimum, an independent operator that's comfortable in almost all situations. And even then, you probably still need help and mentorship from time to time. So, but the bottom line is just ask the folks that are training you about how they think about it and what you can do to become more independent and seek out advice, seek out feedback, and take it well. It's not always gonna be comfortable or fun, but people want you to learn and they want you to be successful. And you will get to that point. Some programs will get you there faster than others. That's just the nature of how they train people. But I would also assume that a lot of the, I was like this and Arash and Alan and Tacey can comment on this. When I was kind of early on, when fellows were in the lab, I didn't do, I didn't have to do very much. But even if they were fourth years or showed a particular interest in the cat lab. So that's just the part of growing as a junior faculty member. And part of what I'm sure Alan and Tacey we have talked about and we'll talk about is the transition from fellowship to early attending is the hardest transition at it's far and away hardest. And we all want to try to get you there and have you be as comfortable as possible. Right, well, he bumps it. We'll see if I can spike it here. So this is the formative years and that transition to attending. So I will say that I do not have any disclosures applicable to this lecture, but I will say that I've made many, many mistakes in this process and I am certainly no expert. And what I really don't want to come off here is a used car salesman selling you something that you should not be buying. But I want to talk about kind of laying a foundation. And, you know, it's been said by many that the fourth year fellowship training is only a warmup for the year that you'll truly learn the most, which is that first year out as an attending. And, you know, this is the typical published learning curve which outlines a slow beginning, steep progress and a plateau that one might reach with a lot of experience. But I got to tell you those first few years out your learning curve looks like this. And there's a big emphasis on the I know nothing phase at times. So in order to kind of lay a foundation for these formative years immediately out of training, I think that you might want to consider a couple of aspects to ensure your success. I think the first is the setup of your environment to ensure mentorship and to generate trust. So the first published core curriculum for training pediatric interventionalists was from 1996 that I could find. You can see their outline sections there of radiation safety, diagnostic cath and the like. But 2005 granted us some new training guidelines. And these included many of those same sections but really emphasize that ongoing mentoring for complex interventions is crucial. And so similar publications in 2014 began to highlight this aspect further, mentioning that newly graduated fellows may benefit greatly from ongoing mentorship by a senior colleague during the early years following training. And I think that everyone needs to consider building mentorship and generating trust as a really a top priority in a new position out of fellowship. I personally was incredibly blessed to have a mentor in Dr. Larry Latson during my first job, to be honest with you, back to Arash's talk, it was one of the deciding factors in choosing where I ended up for my first job. And Larry has a really long illustrious career in pediatric cardiology and decades in the cath lab, but I found his first publications here from 1981 in PubMed. And Larry's patience to really stand beside me and support me in this first few years out post-training is something that I'll always truly cherish and really be thankful for. He always allowed me to perform any of his cases and he was there as a backup for any of mine if I were to call him. And I think that this really kind of created a safe space, if you will, that I could push and innovate within knowing that that support was there. But I really wanna eliminate some preconceived notions and this was alluded to by Tacey that mentorship comes from people outside of your discipline and from those who don't have to be decades or senior. This is it, the top is an ACHD doctor, Todd Roth, that guided me through many clinical situations and decision-making. And the head of our CT surgery was Frank Scholl who taught me so much just about life in addition to medicine. And lastly, I cannot emphasize enough the importance of maintaining and fostering mentors outside of your institution. You know, this is a familiar face to you now, but Arash has been a friend that I could call any time of night or day to ask a question. And you know, this type of relationship is mentorship just as much as anything else. So next up is team building. You've heard that word a lot in order to kind of empower and strengthen the members around you. And now if we go back to our core curriculum for training fellows and search for the word team, you'll find this term just repeated in almost every single section of that one. And this crosses international boundaries. You know, this is the European guidelines for congenital cath training, which referenced the need for a team approach to complex patients just repeatedly. And if you venture into the adult congenital realm, you'll see a similar picture there. In fact, the word team occurs 23 times within this text. And by the way here, you got mentorship that pops up numerous times throughout as well in regards to ACHD patient management and for structural fellows as well. So a former mentor of mine named Robert Campbell, he forced me to read a few texts during categorical fellowship, which I believe have been incredibly useful. The first is this, it's the ideal team player by Pat Liccioni, and this really outlines that to have great teams, you gotta have great team players. And there's kind of three virtues of the ideal team player, which include being humble, hungry, and people smart. And when these virtues overlap, the problems that arise when some are missing can be very evident. And kind of piggybacking off of that, another great book is the five dysfunctions of a team where really the core concept is this pyramid with the base being the absence of trust. And that's really when team members are unable to show any sort of weakness, they're reluctant to be vulnerable and open with another, or they're afraid to admit any mistakes or unwilling to ask for help. And these aspects can lead to a fear of conflict, which is that second row there, and then lack of commitment, avoidance of accountability, and ultimately inattention to the results. So I think it's really crucial to empower the team members around you and to help them help you. You know, a great way to kind of generate trust from your team and to educate is to push for nurses, techs, or trainees to lead the timeouts prior to the procedures. And you can set the expectation that the draw out the anatomy on the board and outline any potential NGOs or interventions that the team might perform and keep them engaged. Because if you engage each member of the team, then really the truth of the matter is that the end result ultimately reflects the team more than any single operator. So next I wanna kind of briefly touch on case navigation and experiential learning. And the first thing is just to remember, and I think it was Brian that said this as well, is that first thing is just ensure that you're present and you wanna be sure that you're helpful when present. And it's really easy to go along your day with a full mind without being kind of mindful of your surroundings. And there's something to be learned from every situation. So you just gotta have the correct mindset to actually grasp the learning that you can gain from each experience. You cannot underestimate the importance of case preparation and not relying on a fellow or a trainee or APP to do it for you. It's really crucial that you're not too scared or proud really to ask for help in any of these processes. And this really allows for an environment to kind of push the envelope and a team that kind of sets you up for success to tackle a big feat. So last one here, we're gonna talk about kind of junior faculty development and progression. And I think that one thing that you gotta remember is that you really do matter and you bring value to the group and you're hired for a reason. And in order to really be a great leader, you really have to start off as a good follower. And it's important to really adapt your practice and all that you've learned in your personal practices to your new institution, because it's a fine line to walk there of knowing when to push for change and when to just follow suit. So I sent a poll out to several division chiefs and cap lab directors regarding junior faculty development in those first few years out. And I wanted to share kind of some of the tips that they mentioned. And the first is that it's really crucial to be confident in yourself and to generate mentorships and support systems. Now, that should certainly sound familiar after all these talks that we've had today. And then it's also really important to be okay with saying, I do not know. You really wanna avoid being not always right, but never in doubt. And I think we all know a couple of people like that. And don't be fooled into thinking that you're gonna conquer the clinical aspect and then be able to kind of focus on other pursuits such as research or program building, QI, whatever your passion is. Because if you don't make them a priority and develop those skills at the beginning, then two years will turn into four, into a decade. And you really wanna involve yourself in efforts outside your institution. Going back to Rupesh's question, you wanna be able to learn from and collaborate alongside others within the field, because that's a crucial principle to this career. So, some last bits of wisdom I wanna cover. Again, these are things that you don't hear about at conferences, but every part or every step of the journey that you've had thus far is very goal-directed. Get into med school, get the best residency you can, go on to fellowship. And once you have a job and you don't have that next step to attain, it's really easy and it's okay to say, is this it? Is this what I've been working for? And you really have to kind of navigate that mindset. And then also, a lot of people warn of a year four-ish stall when you're out of training and really the need to focus on time management, passions and goals. A lot of the things that we've spoken about today in order to kind of avoid a complete life crisis there. And then just, you cannot underestimate the value of just reviewing your work, specifically in the cath world, your NGOs, again, after the case and those of your partners, because you're always gonna learn something. And boy, just be humble and certainly be ready to be humble. But most importantly, you really have to be sure to maintain and protect and foster hobbies, as well as relationships outside of medicine. That's certainly more important than anything that you'll do in your career. So really, I think that's kind of it for those formative years. It's a hard time, but it's a valuable time. And I really think that your learning curve, there's gonna be a lot of, I don't know anything to it, but I promise you that eventually you'll get to it quickly enough.

transitioning

collaboration

mentorship

team building

medical careers