Episode 293: Master Clinician Part 2: Keith Baker
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Hello and welcome back to ACRAC. I'm Jed Wolpaw and I am thrilled to be having our second ever Master Clinician episode. And with me, I have a true Master Clinician, Dr. Keith Baker, who is a professor of clinical anesthesia at Harvard Medical School, the vice chair for education at Massachusetts General Hospital, where he was also the program director of the residency program for 15 years.

It was clear in emails and calls and texts that I got that his peers and his residents and trainees think of him as a true master clinician. And so I was thrilled when he agreed to come on the show. And we are going to talk about the things that he passes on and wants to pass on to those who learn from him. So, Keith, thank you so much for agreeing to come on the show. Pleasure to be here, Jen.

Let's start by just talking a little bit about you. I mentioned that you are now the vice chair for education, but talk a little bit about what your career looks like right now and how you got there. Yeah, I have a very odd trajectory. I was initially going to be a neurologist and then maybe an invasive cardiologist. And then a basic science was supposed to be part of the deal because I have an MD, PhD, PhDs in neurobiology, voltage-gated ion channels, really low-level basic biology, which I started out as doing.

a researcher as a junior faculty member for a variety of reasons that are another podcast, which we won't have today. I decided enough of that after about three years. So I went into my chairman, Dr. Zaypol and said, you know, I'm done with this. And he just turned to me and said, well, how about, how about giving education a try? And I said,

Great. Why not? I'd won a teaching award just showing that the residents liked working with me. And I thought I'd give it a try. And I think the part that's been most effective for me is taking the mindset of a scientist or a clinician scientist who thinks about things critically and wanting evidence for what he does and applying that to the domain of education. That has been something I've enjoyed doing and I think is an effective approach to doing what I do. So then...

So I ended up as a program director and just have kept with it the whole while. It's a never ending thing, this education. Yeah, absolutely. And, you know, I know from from knowing people who have worked with you that people really feel like you have not only kind of charted the way into being a program director yourself, but been an incredible mentor and guide to those to come after. And I think that really says a lot. So thank you for doing that.

Let's talk about some of the advice that you find yourself giving to your trainees, to junior faculty, to mentees, things that, you know, people come to you and they say, you know, whatever they're asking about. And you find yourself saying this stuff again and again or really wanting to pass this on to the people who come after you. What really comes to mind when you think about that?

Probably two things have been what I would call cultural norms for us. And this all stems back from the early 2000s when I was getting very involved in education. And for whatever reason, I became very interested in the development of expertise and thought that had a really nice role in medical performance too. And so

Looking at what it took to become an expert or at least very good in the domain of anything, including medicine, there were a couple of really fundamental elements that caught my attention. I read a lot about and then I tried to bring his cultural shifts to our place and.

One of them was this concept of having what's called a growth mindset or a learning orientation. And that's been the Kool-Aid we serve in our residency and to our faculty on a regular basis so that we have a culture of both learners and educators who are

pursuing what they do with that mindset of always improving when things are difficult and struggle some, so to speak. The goal is simple. How do we get better at that task that's causing us some grief at the moment? So that's been the approach that I think is most important for everything we do. And the second thing probably is the development and utilization of deliberate practice on a regular basis in health care.

Yeah, both so important. Let's talk about each of those. So when you think about a growth mindset, I know a little bit about this actually from a Grand Rounds I heard you give. So it is it just really resonates, I think, with anyone involved in education. But I think we often think and I remember you talking about a growth mindset versus a performance mindset. So maybe just tell me a little bit about what that means and how if we want our learners to have a growth mindset, how do we get there? Yeah, I think, yeah.

a couple of things come to mind firstly i think it's predicated on the idea that things go wrong all the time in healthcare i mean no one wants it that way but but patients you know they become hypotensive or you can't get the procedure to happen like whatever it is you're doing and and things are going wrong commonly people are learning new things that are difficult to understand difficult to apply and so on someone in the intensive care unit you know has a complication so that's normal and

And the key here is when things like that or anything for that matter go wrong or don't go optimally, um,

The goal that you set for yourself can really vary along two different directions. One direction is the concept of improving your competence to triumph over the setback or the difficulty or the challenge. That's the learning orientation, growth mindset, or the mastery orientation. You want to master the task, master the problem, whatever it is you couldn't do, whatever you failed at, you want to get busy at figuring that out, and that's what it's about.

In contrast, there's a very different approach where you're really worried about what other people think about you. It's how you worry about being embarrassed that you don't know something. It's when you can't get a procedure to go on, you worry that someone will think you're not very good at what you do. So you're worried about how you look in the eyes of others. And that's called the performance orientation because you're worried about what people will think about your performance.

And that is not particularly effective. You don't get better at something by worrying about how you look, about worrying about your validation. Instead, you get better at something by worrying about how to actually get better at that task. So seeking advice, getting some counsel, asking for help from others. That's what you would do if you wanted to improve.

If you were worried about what people thought about you, you might get busy saying, oh, you know, the patient was moving too much. That's why I couldn't get the epidural. In other words, displacing onto the patient or saying something like, oh, they must have scoliosis that no one knew about, blaming something else besides yourself. And that does not help you get better, I'm pretty sure. Yeah. And so, you know, tell me if I'm right here, but I think...

Sometimes the way this plays out is if you are – and I think so many of us grow up in our society and culture in a performance mindset. And if that's where you're at, then let's say – this is a very basic example, but let's say that you're very good at intubating with a Mac blade. And so in a performance mindset, you're going to pick that Mac blade every time because you're most likely to succeed and you want to do it right. You want to nail it so that your attending says, wow, you are really good. Great job. Right.

Whereas the growth mindset, you might say to yourself, well, I'm going to actually try the Miller blade, which I'm not very good at. But that means that if I make a mistake, I can get feedback on it from this attending and that will help me work on that aspect of it to get better. Does that is that accurate? That's really well said, Jed. I'd say both in our domain of anesthesiology, it's a really great way to think about it. The one caveat I'd add is you must apply this, the newness, the Miller blade in your case,

to a clinical circumstance which does not have inherent risk with that. So, for example, residents sometimes will ask me if they can use the Miller blade for the first time with someone for a rapid sequence induction to which, of course, I say no. I need the breathing tube in with the cuff up promptly. That's the patient's aspiration risk. So you have to reserve this more difficult, more challenging, purposeful choice for when the clinical scenario is fitting.

Yes, that makes a ton of sense. So how do we take people who have grown up from kindergarten with this idea that they want to the teacher to praise them? They want to get the A. They want everything to look good and they don't want any criticism. How do we help people move to a growth mindset where they're they're looking for that feedback? They want to hear what they're doing wrong so they can get better.

Yeah, so we have spent a lot of time working on that. So the word culture is quite appropriate, meaning it has to become normal. And that's a two-sided deal. The trainee has to want to grow and improve, and they have to be working with an attending or a supervisor who

who is supportive of that. So if you have a growth mindset trainee who wants to try the Miller in this case, and the faculty is like, no, no, no, just get the tube and get it over with. Then you have a conflict. And we, we try hard to, uh,

support the enculturation of a growth mindset in both groups of people, both trainees and faculty. And I think the evidence in the literature is quite supportive that the growth mindset is the optimal way to go in difficult circumstances. And so, again, as I mentioned before, my real motivation is to apply evidence-based evidence.

to medicine. So just taking that concept, we can right away map this process onto healthcare because there's been the randomized trial looking at people learning to try to tie surgical knots and randomized to both growth mindset approaches and performance or validation mindset approaches and

And you tie better knots when you're in the growth mindset, learning-oriented milieu. And that's because you're focused on the task itself, which is what we're about. If you're worried about yourself, that drives up your anxiety, that gets busy in reducing your working memory capacity, which is the part of your brain necessary to think and decide what to do with your hands to tie the knot in the first place. So anytime you...

increase anxiety by worrying about yourself, you almost always decrease performance in cognitive or even spatial things from kneading your hands. So I think the evidence, that's one example. There's a whole lot of evidence saying that, that, um,

Working towards a growth mindset both in how you think about things, how you frame things, and how you talk about things is quite important. So another way we do it as a cultural norm at our place is that we do not give our residents their so-called scores. In other words, our faculty do evaluate our residents with numerical scores, and they also provide comments that are designed appropriately.

designed to help them improve in performance. We share the comments with the residents and their mentor so they can look at the material that faculty think will help them get better at what they do. We do not share the scores because that provokes comparison amongst other people or peer comparisons, which is known to provoke a culture about comparisons and performance orientation and validation orientation.

Those scores are available for them to look at if they want them, but it is countercultural, so we do not give them to them. And that's a purposeful thing that we do. At the same time, residents need to and want to know that they're doing well. So when they're doing appropriate activities, they are doing things correctly. We share that with them too. So I don't think that being blind to doing well is a good idea, but by all means, focusing on

Always asking the question, how do I get a little bit better today versus or tomorrow versus today is really the issue here. Yeah, that sounds great. Let me ask you, when you're working with a resident in the OR, are there things you say either beforehand or in the setting of them, let's say, being unsuccessful at an A-line or an intubation to say,

try to make it feel like it was okay to make that mistake and that absolutely yeah and what do you say to them yeah oh absolutely uh you know i i do a lot of doubling tubes with thoracic cases and sometimes it doesn't go where it's supposed to go it's a big thing

And I'm like, that's okay. Let's just figure out how to put it in the right spot. I mean, honestly, these are trainees. They haven't done it many times. For them to put it in the wrong place is what I would call normal. Not that I want it to go that way, but it's completely part of the learning process. And so I am extremely forgiving of things that don't go well.

If I've told someone to do something a particular way and they refuse to do it, that's another story. So I think failing as part of learning is normal, and I'm very forgiving of that. And the voice I use, the...

The way I say it, the tone I have makes it real clear that it's okay. No one wanted the thing to go on the wrong side. No one wants to have the tube falling out or whatever it is that's going on. But let's fix it. Let's figure out how that happened so it won't happen again. And how do we correct the issue in front of us, whether it's

The inability to get the A-line in or central line or the breathing tube, whatever it is. And like I said, it's always something. So I really do think that helping them grow, if your goal as attending is to help them develop, become better at what they do, trainees are very, very tolerant of that sort of input. Yeah.

Yeah, no, I agree. Absolutely. I'll say, you know, if let's say a resident doesn't get the breathing tube in and I have to do it, you know, I'll say to them after, especially because I'm the program director, right? So I know that they feel horrible about that. And there's only so much you can change. But I will say, listen, believe it or not, I'm glad this happened.

Because if you had nailed it on your first attempt with no problems, I really wouldn't have been able to teach you anything. But the fact that it was a difficult one means that, you know, that's great. I can make some pointers for you that may help you with the next time you have a difficult one. And that's great. So I say that. And then I'll also just say, listen, it's happened to me a million times, right? I just try to normalize. Like you said, it's normal. I'll say not only is it normal for residents, it happens to me too. And I think maybe that helps a little bit.

Yeah, I think so. One other item, whenever I can, if I can correct something such as how to put, say, an epidural into somebody, I will a lot of times, or if I can laryngoscope somebody and demonstrate the glottis, I will show them what I can see and go, and then I'll go, and I back out and I go, now your turn, you do that. So I try and demonstrate what it is I would like them to do, that it is possible. And that's the key. I'm not asking them to do something that's impossible.

But I'm showing that it is achievable, and then I give it back to them. So a lot of times the procedures will go back and forth between me and the trainee. As they try, I show them. They try again. And sometimes it doesn't work out because, again, they're new to the game, and I have to do it. And like you said, they hate that. Yeah, and I think that takes such –

confidence on the part of the attending because you're a little stressed, the tube's not in or the surgeon's breathing down your neck and the line's not in or whatever it is. And the temptation, once you actually take over, to just do it and be done is huge. But to not do that, to do what you said and to say, listen, okay, I'm going to show you, there are the cords. I could put this tube in, but I'm not going to do it. I'm going to hand it back. Of course, this is all assuming the patient's still satting fine and stable. But that, I think, takes a lot of confidence but can be so rewarding for the trainee if the attending is willing to do it.

I agree. It is incredibly rewarding. It also provides autonomy to the trainee to give another try. And that's critical in developing the milieu of autonomy and the ability to do things correctly and relatedness with the trainees, which is all part of motivation. The other thing that helps motivate me to do that kind of activity while the surgeon's over there tapping their foot is my job is to

promote education. It's to protect the education mission. And, and,

Today's healthcare system throughout our country, I think, are strongly designed for throughput, industrial care of the patient at speed, and education gets essentially mowed down. So I do think that faculty who've got the wherewithal to do it really need to put up the guardrails and protect education because it's one of the first things to get run over in the

quest to do more cases more quickly. And so you really do need to believe in what you do and believe in the value of education to develop the next generation of physicians. Yeah. All right. Let's talk about the second thing you mentioned, deliberative practice. So give a little definition. What does that mean? What's the difference between regular practice and deliberative practice? And then how do we see it or how do you recommend people use it?

Well, deliberate practice is quite different than practice. Most of us can think of, you know, the so-called practice of medicine, which means doing what you do day in and day out, trying your best, that kind of a thing. And so if you were to think of medicine,

Any activity where you do it a lot of time and time again, that's practicing that activity. Deliberate practice is quite different. It's really purposeful. It's asking the question, what part of my performance do I want to improve on? It's isolating that element of your practice and then designing activities to improve that part of your practice, getting feedback, trying it again. And so it goes. It's effortful.

Does not result in immediate reward in general. Actually results in failure quite a lot because you're trying something new and you're pushing yourself at the upper levels of your performance capabilities.

But with repeated activities in this domain of deliberate, purposeful, effortful, focused practice, you will get better and better and better at what you do over the course of time. It's a slow process ridden with failure, as I've already mentioned. So if you just keep with the Mac 3, we'll go back to that analogy, Mac 3 every day, you're going to be as good as you get with a Mac 3. But the day you need something besides a Mac 3, you'll have no game because you have not developed enough.

all the other methodologies that are available out there. So had you been busy developing those methodologies in your practice, you could turn to them quickly. Try this, try this, try this, try this. One of which would probably be successful for you. So I would say that you have to be very purposeful. The tyranny of the day, as I call it, will get to you and you'll get through the day. Next thing you know, end of the day and nothing's been practiced.

Instead, I do like it when residents say to me, hey, can I try the Miller blade? Because they know I'm permissive of that and I'm experienced with that. So I try and show them how to use it, the methodology of making it effective for them. And so it goes. There's a lot of things we do. But the point is you have to come in each day with something on your plate, on your agenda to practice purposely to make your performance a little bit better in that particular domain or area. Yeah, I couldn't agree more. You know, and I think that

I tell the residents, if you... I'm going to be more impressed if you come in and say, I'd like to work on this. I feel like I need some work on this. And then you try it and fail at it than if you just go with what you are the most comfortable with and you nail it. Because again, in the first case, you've got something to work on. I can help you. In the second case...

Might as well not be there, right? There's nothing I can do to help because you just picked what you were already really good at. So it's hard. And the deep inertia, right, takes us, I think, to just wanting to do the easy thing. We're tired. We're working a lot. And so to just do it the way that you know it's going to go the most smooth, that's tempting. But I think we need to help push our trainees, and we hope they push themselves to embrace deliberative practice as hard as that is to do. Yeah.

Yeah, the deliberate practice today in today's environment is particularly, I think, challenging because of, again, the large environmental push to move fast, move efficiently. And deliberate practice is not efficient. By definition, you're doing something new. It's slower.

So it does need, again, some defense. It needs some protection. It needs some people who can go, hang on a second. We're going to do it this way. It'll be okay. It'll take another minute, but we will be successful. And I used to tell my attendings when I was a resident to get them to play along with me. I'd say, tell you what, I'll try and use the fiber optic for five minutes. If I can't get the thing in in five minutes, I'll turn around with a blade and intubate the patient. Because that way there, I gave them what they needed to know, which is the fact that ultimately I won't spend all day doing this.

But I would carve out a bit that was just for me to develop my skills back as a resident. And that seemed to work often enough just by giving them that out. They felt okay in giving me a few minutes to practice using the fiber optic bronchoscope to intubate somebody, for example, while they were asleep.

I love that. I've never heard that. And I absolutely love it. I think that is a stellar suggestion for folks to try. It really, I can imagine it really alleviating some of that stress on the attending side of saying, oh, my God, you know, I'm signing on here for a 45-minute intubation.

where you're saying, no, I want five minutes and then I'll let you step in or I'll do it the other way or whatever it is. And that really, I think residents would find a lot more opportunities for deliberative practice if they do it that way. Yeah, it's funny you say that because when I speak to the residents about deliberate practice, I've developed an algorithm for deliberative

Like when to choose it, what kind of patients to choose it on, and so on, including the very common no, you can't do that from the attending, which should then provoke them, according to my little algorithm, which is to ask them why. What is it? Tell me about what is leading to the no. Hear out the attending's concerns and then design a workaround. Whatever it is that they're concerned about, design a workaround. One of the –

complaints I got when I was a resident was, oh, you can't use the bronchoscope to intubate because it might be the last bronchoscope that we have available for an emergency and you're over there playing with it. And I said, tell you what, I'll make sure it's not. How about the next time I'll make sure it's not the last bronchoscope. And if that's the case, then can I use it? So I would alleviate their concern by checking that I was not taking the last bronchoscope that might be needed for an emergency. And you can usually work through some of the concerns they have, which are real and reasonable and not that hard to develop a workaround on.

Fabulous. I love that. Okay. Another thing I know that you are a big proponent of is using original literature, knowing the evidence and trying to practice evidence-based anesthesia. Tell me a little bit about that. What do you recommend people do to really feel like they are using the literature appropriately?

Yeah, this probably developed from my time as a PhD student where you kind of just read the original literature. By definition, you're doing new things as a PhD student. It's all new. You have to be reading basically primary literature because there is no book telling you the answer. So I became very –

fluent or comfortable reading literature, in other words, journal articles. And then as a resident, I started reading textbooks, which I call the landscape view. It gives you a big perspective on, you know,

whatever it is that chapter is about, which is, I think, quite helpful, actually. But then as I was reading these chapters, they would make references. I would read the references because I found them interesting or they were confusing to me, so I'd want to read more. And I found a lot of the time when I would read the original literature that was cited in a big old textbook, that

There was a difference in what I read and the meaning from that paper and what the author wrote. So I thought that I probably ought to stick with the original literature as often as I could because then I was getting the original meaning, which is oftentimes changing as I hit a textbook. The problem with the method, of course, is it takes a ton of time because original literature papers are arduous to read, at least when you're new to the game. And so it is not an efficient way to go. You have to like reading, and I do.

So I don't recommend it as the initial approach. I recommend the textbook to give the general view of things. And as soon as you want depth, get beyond the textbook into the original literature and then find out what is the quality, the depth, the, the, the, the,

of the original literature. You might find out that the belief you possess is based on nine patients that weren't even randomized, to which you should be relatively horrified if you believe something based on that. Could be true, but it's very likely not. And so I found that by reading the original literature, I could quickly adjudicate whether something was

likely to be true, likely to be changing over time because the quality of the evidence was not very good. And so I think it's quite helpful to get at the veracity of the material by reading the horse's mouth, so to speak. Yeah, fabulous. So are there things that you find yourself missing?

teaching people, Hey, what, you know, things that people are doing a lot and you're, and you find yourself saying, you know what, that's actually not what the evidence tells us. Oh yeah. Yeah. Very much so. And give me some examples of that.

Yeah, so they take all forms. I'll give you one example that's very common. The use of lactator ringers to replace blood loss. If you ask, I'd say nearly anybody, by the way, if I lose a liter of blood, how much lactator ringers should I give them back? You'll hear them say three to one. That's a pretty reliable finding. And to which I usually ask where they learned it, because I'm curious where they heard that from. And they'll say a book or a class or something like that. And

And if you read the original literature, and there's a lot of it on this one, this is clearly not correct. It's five to one. So if you give a liter of crystalloid after it's redistributed, which takes about an hour to be fully redistributed, you only get to keep 20% of it. So 200 cc's. So if you want to

replace a sizable blood loss with crystalloid, you need to give a lot more than you think you do. And what will happen if you do three to one, which is taught and believed, you will have a hypovolemic patient real fast if it's a large volume you're trying to fix. I think the reason it doesn't

matter a lot is because bleeds are tiny. Let's say it's a 300cc bleed. Well, you don't even need to get replaced at all. You go to the Red Cross, you donate 500, no one gives you crystalloid back, right? So we can be wrong and get away with it, but I would submit if you want to be normal volumic and that's your goal, then your blood loss needs to be replaced five to one at steady state. And the support, the data for that is extraordinary. That's probably not the sort of thing to

argue about that the data are there for that yeah and i think you're right that that is very few people do that so that's uh i think people just don't know and i would agree with you that probably the three to one for most people comes from the medical school that's probably what they were taught in medical school and that's what that's what they are still using another another good example that i see uh physically happen uh routinely at my hospital is that uh

A trainee goes to laryngoscope a patient. They don't get the view that they were hoping for. And the very first thing they do most of the time is to start pulling the blankets out from underneath the head of the patient to extend the head to which I'm like, no, no, no. Put more blankets behind the head. All the evidence says it's the other way around. So the intuitive desire is.

To pull blankets out and extend the head is extraordinary. And it is almost always done. Every now and again, you'll find someone who knows better. But in general, people do that. And the evidence for the contrary is quite high. Actually, it's very, very good. And so flexing the head, including flexed neck and flexed head on the neck, is the method used to expose the glottis in the most difficult of innovations to

Now, the downside, which is quite real, is that your working room is quite small. So you might get a fantastic glottic exposure seeing even a grade one view, but have a very difficult time putting a breathing tube into that exposed glottis because of all the tissue being smushed. So sometimes you'll have to put a bougie in, take the blade out, extend the head, and then put a tube in over the bougie. But you can get glottic exposure to be much improved by breathing.

raising the head, which is quite the opposite of what most everybody does. And again, the literature for that is very good.

Yeah, absolutely. One of the things that always makes me laugh a little bit is when people take the pillow or the blankets out from behind the head and then they can't get a view and then they lift the head, which is putting it right back where it was. So, yeah, it is funny that there's that instinct to take this stuff out from behind the head. But I tell them the same thing you do. Are there are there things that you feel that you do and you teach that there just isn't?

you know, you kind of have to do the best you can because there isn't good evidence for it. I mean, for or against. And so, I mean, there are lots of that, right? Yeah. And what do you do in those situations? So a couple of things. Number one, there are two aspects, and I'll give you an example of each that I think are really quite germane for my behavior. Number one is when I do something and I know there is no literature. And one tip I tell folks is that if we're going to have an unprotected airway, such as

an LMA or a deep MAC with an oral airway, for example, I will ask the person to administer all of the anti-emetics up front. Now, there's no shred of evidence for that whatsoever, but I'd hate to have them vomit with an unprotected airway during the anesthetic because of the unpleasantness of aspirating. It's not a good thing, obviously.

And I'm very clear. I have no evidence for this. This is one of my practice behaviors that I do because it seems like a good idea, but I can't support it with any evidence. The other thing I tell people about is what I call the number needed to treat. So I am quite willing to do something that will benefit almost, I can't say nobody because that would make it foolish, but I am willing to adopt a day in and day out behavior pattern

for maybe one in 100 to one in 500 wins. So for example, I will make sure that my patient has at least 90% restitution of neuromuscular transmission by acceleromyography measured very carefully with fixation of the hand and all this before I will wake the patient up. I demand basically that they are fully reconstituted at the neuromuscular junction before the wake up.

Other people get real close. You know, they give them the Sugambidex, patient seems real strong, and then they pull the tube out. That's not my style. I can't prove that my way is any better. But I know that if I occasionally make a mistake and I only got to 80% because I didn't measure, I got in a hurry, then I'm likely to hurt a person not often at all, but once in a blue moon. And if I can avoid that by being patient,

particular on a daily basis, then that's what I do. And the same way with ARDSnet Tidal Vime. I set ARDSnet Tidal Vimes for everybody, even though their risk of lung injury is very, very small for a lot of the patients. But once in a blue moon, you know, I'll take care of an esophagectomy patient and

using ARDSnet tidal volume, who will then post-operatively have an aspiration event. And then they have two hits. First one given by me because I was using too big a tidal volume. Second one given by the aspiration. Then we have the, you know, the consequent of two injuries to the lungs, which are usually quite problematic. So I try and erase any of the first hit aspect, which is to make sure I'm ventilating with ARDSnet no matter what, because I never know when the second hit's going to come or the shock episode's going to come after I've, you know, done something aggressive to the lungs that I didn't need to do, if that makes sense. Yeah.

Yeah, I love that because so much of anesthesia is preparing for things that may not happen or maybe even frequently won't happen. But the day in and day out practice of those good practices, like you're mentioning, will probably help at some point. And it's relatively harmless for us in terms of time and energy to build in those habits.

Once you've built it, it's probably just second nature for you. You're not thinking about, you know, the trouble you're going through to kind of measure the twitches or to program the vent. That just happens second nature. And so then once those habits are built, you get the benefit that will come every once in a while. Yeah, it's all about the habits because habits are mindless and mindless is easy. So if you can get a good quality habit that's taking you right down the middle where you want to go, then you've made your life easier. Yep. Stay with us. We'll be right back.

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All right, and we're back. So let's say you have a resident or a young faculty member who says, you know, I really admire how well you know the evidence, the literature. I want to be like that. I want to really figure out how to be really knowledgeable about the literature. What advice do you give them to kind of start building that habit or to what should they do on a daily basis, a weekly basis to eventually be able to have a really good grasp of the literature?

So I think the word habit was used by you a moment ago, and I think that's the operative word. So every day, choose something to read. And as I like to say, I used to have two piles when I was a resident, the pile I wanted to read and the pile that I had to read. So to become a board-certified anesthesiologist, I had to read everything, including stuff that didn't inherently interest me. And then there was stuff that interested me.

And I read from both piles. But when I was not feeling like I could read something that just didn't interest me, I would read from something that did interest me from the original literature. So in my case, I read a lot of physiology about how the body works, the heart belongs and so on.

And I find that interesting. It's easier for me to read. And when you start to read, initially it's difficult because the techniques are you don't know the methodology is complicated or the statistics are complicated and so on. But as you read them and work through them and develop your understanding of the methodology and the statistics and so on,

It becomes easier and easier and easier. So the more you do it, the more you do it, the easier it gets. And so it goes. So these days when I do share primary literature on, say, something like the cardiac contraction of the time-varying elastance model of cardiac contraction with the residents, and I share Suga and Sagawa's original papers, the residents have a really hard time reading those papers because there's a lot of

And in other words, you know, controllers looking at flow or volume and pressure over time, feedback loops, cross circulation of the ventricle and so on. And that's a huge cognitive load to the resident. And so you have to read that stuff.

on from various, various papers, go through it a bunch of times. And then finally it becomes not so bad. And once it's not so bad, you can read more. And so it goes. So I do think there's an upfront investment that has to be made to develop some fluency with actual literature and developing that's critical and making it a daily activity. A paper a day, at least is, is what I would recommend and,

It makes what you do at the hospital much more interesting every day. While I'm doing a case, I'm thinking about these sorts of things, which then stimulates the next inquiry into the original literature. Why this? Why not that? And because you have facility with it,

You can make those inquiries of the literature to see what's out there. And you can likely understand the papers if you try a little bit. So I think it's a daily habit, you know, no more than a day off or two in a week would be what I would suggest. Great. I think that's great advice.

Now, I know that you and I do this, too. You recommend to junior folks to try to say yes when asked by someone in leadership to take something on or to do something. And, you know, tell me a little bit about that. What is the benefit to that for people? And then if you could maybe give a couple examples of things that when you were a resident or junior attending that you said yes to that kind of worked out in ways that you didn't foresee initially. Yeah.

Yeah, the saying yes, I think is important because at first opportunities are going to come in ways that you may not see. In other words, a lot of people want to do

I don't know, a certain activity in the department, but that activity may be locked up in somebody else's domain for some time. So you don't have access to it, but an opportunity somewhere else may arise and provided it's not, you know, an atrocious activity, probably saying yes and giving it a try is a good idea. They're giving someone's showing you trust when they ask you to do something there, they think you can do it. They wouldn't ask you if they thought it was going to not work. So they think something of you. And then,

By doing it, you'll develop some connections with other people. You'll develop a more sophisticated version of thinking about that activity, whether it's developing a compensation plan for your faculty, whether it's developing faculty development, it doesn't matter. Whatever it is, you're going to develop some facility and sophistication with it. And that's good for you and it's good for your department. So it's sort of a win-win. And then as you get to

be effective at whatever that is you've been asked to do, then you can become fluent at it. And at some point, if you want to move on, then you can ask somebody else to take over and help them transition to the takeover, and then you can do something else.

Uh, in my case, um, uh, two fun stories I had one, one was, uh, I was, I gave a talk about Venus return at the ASA. I gave a refresher course to a lot of people and, uh, I got that opportunity because, uh, someone heard me talk about it at the MGH and, uh, suggested I talk to the ASA and I said, sure. So that talk went well, but somebody in the audience asked me to come give a talk on, uh, the, uh,

pressure waveforms and arterial lines and then something about cardiac output.

and over in Sweden. I thought, oh boy, that's difficult. I've never done that before. From what I knew about it, figuring out the cardiac output by looking at an A-line trace wasn't very effective back then. I thought, well, I'll read all about this and I'll share with them why we shouldn't do it. I started reading all about it and I realized, well, sure enough, you can't predict cardiac output from the arterial line trace, but you can very effectively determine volume responsiveness from the arterial line and pressure-volume relationships in positive pressure ventilation.

So I realized, wow. And with my knowledge of the circulation, I could put together a really nice talk about how the heart and lungs interact with each other and how positive pressure ventilation was a great perturbation to discern whether or not you were going to be responsive to a volume input. And I put together a nice talk that was a

I've been using ever since, since, you know, 30 years now or so, well, 25 years. And that was all from saying yes to something I thought was going to be a no-go in the first place. But I was wrong in my, in what I thought I would get out of it. And I grew from it and learned a lot from it and was able to apply it to this day. So I think it's a very nice story about how saying yes can actually pay dividends, even when you never saw it coming. And the other one, of course, was the day I went in to tell my chairman that I was done with basic science.

And he asked me quite out of the blue, it really was, if I wanted to become involved with resident education. And I said, well, sure, I'd give it a try. And that was the beginning of my activities with training, being a program director, and so on, so on. And it really has been the focus of my career as to how to generate excellence in our trainees as they learn our specialty and go off to do the things they do. So I think it's been, I mean, a

a great opportunity to say yes to something I had no idea what I was getting into, and it worked out quite well. Well, that has got to be one of the all-time great examples. So here you were, an MD-PhD, coming into your chair's office just to say, I'm not going to do this anymore, with no thought of resident education. And he...

fortuitously brings this up and then you become one of the all time great program directors. So, you know, that is such a great example of of how just given things to try can work out incredibly well, not only for you, but for many, many people who had the pleasure of learning from you. So I'm glad you said yes to that one. Let's let's talk about teaching. So when junior faculty come to you and they say, you know, I'm really interested in being a better teacher. What advice do you give them?

So, like anything, you know, harking back to the original literature on For Most Everything, there's an awful lot known about what works and what doesn't work. And so reading to get the schema of how to think about education. And so I meet with all of our new faculty and give them some advice.

core reading to do, try and keep it minimal because they have a lot of things on their mind. So, maybe two or three papers on sort of the science of education, like what does work, what doesn't work, and what sorts of things get you in trouble and what sorts of things are residents wanting. And so, by trying to focus on things that they have control over, that's key because you give them autonomy.

Giving them some structure to know what is an effective thing to do, then they can choose to do some of those things. And then giving them a list of the things that get you in trouble so they can be aware of those and then minimize any of those activities if they happen to engage in them. And for example, I did when I was a junior faculty. I was a sarcastic person more than I am today.

And I used to think I was pretty funny with my sarcasm, but it turned out due to the feedback I got, it turned out the residents didn't find it so funny. They found it off-putting. So I realized, well, I don't need to be sarcastic. I thought it was funny, but it turns out I was wrong and I was more of a nuisance than I was worth. So I thought they'd given me feedback.

I think it's correct, meaning I do do that. And it's also not helpful and therefore I can suppress it. I still tend to want to be sarcastic at times,

But through self-regulation, I suppress it quite a lot. And so my teaching has gotten better because I don't have that negative element as such an active part of my behavior. So by giving people the list of what gets you in trouble, sarcasm being one of them, you can help shape what they choose to do and not do. And if they can use the original literature, boy, that helps immensely. So teach from a point of strength, which is if

If you're going to teach a topic, make sure you can produce a paper that's a high-quality paper that supports what you're saying so the trainees got something to take to the bank, so to speak, and can lean on for the rest of their career, at least initially.

Right. I think that's super useful. And there's I find I'm sure you do, too. There's so many folks who stay. They finish training residency or fellowship. They take an academic job. They they love teaching. They want to be a good teacher and they need some guidance. They're just not you know, all they know is that they were once a learner and now they're a teacher and they want to do it well. But they they need some help. They want to know how to do that. So having some concrete advice can be really helpful.

Yeah, we have an evaluation and feedback program for our faculty that we receive from our residents. It was designed so that you get actionable feedback. And it was, I used to have, I designed the one we used for many, many years, which I think was pretty good. We wrote a paper that it was effective. But I think the next generation, I'll call it, was instantiated by our current program director, Dan Sadawick-Konefka, which I really appreciate, which is basically he's turned it, instead of residents having to write down what they think about

your teaching, they actually could choose from a list of attributes, which makes it really easy and also makes it de-identified. And by looking at your histograms, you can take a look at your strengths and weaknesses and decide where you want to focus. And that's quite nice.

So that's been very helpful too. Yeah, I've seen that system, Dan, has come up with it and I love it. I think it's fabulous. Let's talk about, I know you like to suggest that people do kind of a deliberate learning when they are going to order labs in a case. What do you recommend people do to kind of get the most learning out of that situation? Yeah, whenever you're going to, whenever a resident orders, name your favorite lab, blood gas, glucose, hemoglobin, whatever, lactate, whatever.

I completely expect to have thought through what I anticipate that value to be. So the other day we had a patient, they lost control of some vessels. There was some bleeding. We put the volume all back.

And we sent the lab off and I said, the resident was about to send the lab. And I said, wait a second, you can't send that lab until you tell me what you think it's going to be. Because in doing so, you are unveiling your belief of what has gone on. You're putting together how much blood you think came out, how much volume you put back, how much is dilutional and so on. So you're really demanding that they have a schema and an understanding for all of the moving parts of

That would result in the lab value that you anticipate. And so we all had our guesses and, and the surgeon, he guessed too, just for fun. And, and we actually all pretty close. We thought the hemoglobin would be in the eights and it was eight four, but that gives you a sense because the surgeon was somewhat aghast at the blood loss. It was pretty high. And so, and,

And it sort of made him come face to face with the fact that, wow, the hemoglobin went from 14 to eight. That's a big, big drop. And so therefore he bled more than he thought he did. That causes you to face the sort of the,

The things that are going on that you may not like with the laboratories. And if, you know, if the lactate's going up and you think it's going to be two and you find that it's five, that's a problem. You're missing something on your resuscitation or a vessel's been tied off or something's going on that you don't understand. And that is a form of a metacognitive alarm like, hey, I don't get it. I'm missing something. And I think that's a very powerful way to understand.

Take your understanding of the situation and put it to the test on a regular basis. Same with glucoses. You give some insulin. What's the next one going to be? You should have a really good sense for what it's going to be. And when you're wrong, that's the information right there. Yeah, I love that. It's not something I do, but I'm going to start doing it. I think that's a fabulous teaching technique. What about when a surgeon asks you,

something that just doesn't seem to make sense. They ask you to do something and you can't, it doesn't seem like a good idea or it doesn't seem, you can't figure out why. What do you recommend people do in that situation?

Yeah, so the first thing to do is explore what they're concerned about. And that usually means asking, what are your main concerns? And asking it in a way that is not confrontational because we're not looking for a fight here. We're looking to understand what are their concerns. And so asking with a tone or a spin, as I would call it, of curiosity is critical. Like, oh, what are you worried about? As opposed to, well, what are you worried about? It really depends on how you say it.

And when you hear what they have to say, then you can address what it is they're concerned about. So, for example, I recall a day some while back and the surgeon said, just, I mean, right over the drapes, give some FFP. And I wasn't about to give FFP to this patient who came in from home for this procedure and it wasn't going very badly. So I bellied up to the drapes and said, what are you seeing that's bothering you? What are you concerned about?

And they said, oh, he's bleeding, he's bleeding, blah, blah, blah. He's bleeding inappropriately. I said, okay, well, I said, you know, the guy came in from home. He's got no abnormalities that we know of. But tell you what, let's check to see if I've missed him. Maybe he's got a...

He eats warfarin for fun. What do I know? So I sent off some basic labs, the sorts of things that would lead to bleeding. They came back in a short time and I said, oh, look at this. They're all normal. So I think we don't need FFP. And he said, yeah, yeah, fine. Don't give him any FFP. So I heard what he was about, what his concern was.

I don't know everything. Maybe the patient did have a bleeding diastasis that I'm aware of. Maybe they have something like a platelet abnormality that's newly discovered during this case. Crazy stuff happens. So I'm willing to hear their perspective, address it, show some respect for the fact that something is amiss for them, and then true it up with how I see the world and come to some sort of middle ground about how we're going to do it. I had one recently with a person who had Fontaine.

And the surgeon said, so we're going to do a robotic case. And I said, hang on a second. I'm concerned about this, this, and this. And to which the surgeon said right away, oh, yeah, I hadn't thought of that. And so we quickly got to a better understanding for a case that really wouldn't have done well with a pressurized hemithorax with CO2 in the face of a Fontan physiology. So by treating your patient,

other person that you're interacting with, with curiosity and understanding, I think it can, it can help most of the time. It doesn't always work, but most of the time. Yeah. I think that's a great point and really helps facilitate good communication with our surgical colleagues. And like you said, sometimes we're going to point something out they didn't think of other times they may bring something up that we realized we didn't think of. And just having the communication is so important. Yep. So Keith, when people, and this happens to all of us, of course, uh,

I think as residents, when we come across gaps in our knowledge and skills, that's kind of expected. That's because you're a trainee. That's one of the things you're there for is to build and fill those knowledge and gaps in knowledge and skills. What about for a faculty member? I think it's sometimes a lot harder. I think it's kind of bimodal. It's hard.

You know, I think it's relatively easy to have gaps in your skills when you're a new resident. I think when you're a new faculty member, it's relatively hard because you feel like you're supposed to know things and you may not. And then I think when you get to be more senior, you're for many people fine having those gaps again because you're more comfortable asking. But what do you what do you tell people if you if they come across something they don't know or something they're uncomfortable approaching or dealing with? How do you recommend they deal with that?

So the growth mindset here needs to come right there and sit in your lap. I mean, this is where the growth mindset culture helps faculty as much as trainees, because if you have that mindset, then you're going to ask somebody. So we link up all our new faculty with more senior people in the department so they have a connection for who to ask what. And so, I mean, I know the folks in our department these days, so in my case it's pretty easy. I would just go to someone who I knew knew the material I was –

I had a gap on and say, hey, what about this? What about that? Can you send me a paper? That would be a great place to start my reading or something. And so I very quickly leverage my colleagues who are great at all sorts of stuff and

and take advantage of their expertise that I don't have. And for some of the stuff I'm never going to have for a variety of reasons. So I am very comfortable allowing there to be sub-experts that I just, you know, am amazed by and that I will never have. I'm not even going to try because it would take so much time. I'd have to have a second life or something.

So to me, asking your colleagues for help, for discussion, for thinking things through is probably one of the first things I would do if I had colleagues that have the sort of information and expertise that I had a gap in. Whether for me, it's like, for example, what I call off-axis blocks or peripheral nerve blocks. I don't do those.

And I have a lot of people in my department who are really good at those. And so I quickly go to those people and ask them all sorts of questions and I have no problem doing it. And it shows, it shows respect for your colleagues to ask them questions. It shows you care and that you, you don't have the answer to everything. It gives them a, a nice space to be kind of the, you know, the expert in something. So I think it's kind of a win-win move to make. Now,

Now, if it's something that's really critical and that I have to know myself, that's different. Then I have to actually go learn it and ask how to do it and have someone watch me or something like that.

Yeah, I think the willingness to ask for help is so crucial. And like you said, it's all about a growth mindset. The growth mindset shouldn't turn off just because we finished training. And also it's as an attending, if we ask for help, it sends such a great message to our trainees, right? When they see attendings asking other attendings for help, I think it helps them feel like it's okay to ask for help.

Yeah, that's sort of a cultural behavior pattern. If you do it as an attending, then the trainee can go, oh, I don't have to try and prove myself all the time. Even the attendings over there asking for questions or advice or whatever. So, yeah. Heath, what does it mean to have a brand and to develop that brand in your career?

So I hadn't thought about it very much. It's sort of a newer term for me. I've been thinking about it maybe 10 years or so. And an early example came when I overheard a cardiologist who was a famous cardiologist at our place who was giving some talks at a national conference. And he had his fellows giving the talks at this national conference.

And the fellows got up to give their little spiels at this National Cardiology Conference, and they were telling a bunch of jokes. And the cardiologist afterwards said, what are you doing? You're supposed to be up there talking about this situation in cardiology, whether it's, you know,

predicting myocardial infarction in the perioperative time, space, or whatever it was. And they started out with jokes. They said, you're branding yourself as a comic. You're a lightweight. You're not a serious contender. What are you doing? And so right then I thought, oh, yeah, depending on how you comport yourself and act, people will draw conclusions and may or may not listen to you because of the way you act.

But it's it's the actions you take belie a lot of other things. So it's a complicated thing. So in case of me, my my brand, I think you would ask what a residence think about when they think of Keith Baker. They think, oh, that dude's serious. He's intense. He's really into doing a good job of what he does. And that's all true.

I mean, I've gotten criticism on my own resident evaluations for teaching in the middle of the night. And the criticism is, dude, give it a break. It's we're on call. Just leave it to be. And I'm like, no, we're here in the middle of the night taking care of patients. We're going to we're going to keep pushing and learning and growing. So that's how that's going to be. So it is you get the feedback and you have to decide.

Is that me? And the answer is, yeah, that's me. And then the next question is, is that okay for what we're talking about? And in my case, I said, yes. So I continue on with that brand. I'm the guy who's all about improving. That's me. And people, I'm also the science of teaching guy. I mean, people think of being, they think of, oh, Baker's going to have a paper about anything educational because I read a lot and I find this stuff in other domains that are not from medicine.

So that's the brand. People link those two things. We have one of our guys, you know, we have a couple of folks who are the cardiac rhythm folks, and I can just list off their names, one, two, three, and they're just those people. Their brand is anything cardiac rhythm device, them. And so I think it can be quite useful, but you won't get a brand unless you stick to it, unless you...

exemplify it on a routine basis and people get to see that that keeps happening again and again and again. So, uh, the other thing is if you decide that your brand is not what you want it to be, you need to a find out that that's true. If you think you're the cat's meow in resuscitation and, uh,

Turns out that people don't really want you around when things are going wrong, then you're going to have to figure that out. You need some feedback and then you need to determine what to do to make that different because you'd like your brand to be consistent with something that's okay for you.

Yeah, that's a great point. And do you think it's possible to change your brand? And if so, you know how I mean, yeah, you're like you said, you have to know what it is first. And if you find out what you're how you're seeing what your brand is, and if you decide that's not what I want, or maybe you liked it for a while, but you decide, okay, I don't you know, maybe you were that jokester, like you mentioned those cardiology, you know, and that sort of seemed fun. But you realize that I actually I don't like this because it is people are seeing me as kind of a not serious person. I want to change that.

Is it possible? And if so, any thoughts on how one can go about doing that? I think it is possible to a degree. A lot of what we do in our behavior is pretty, I'll say automatic, meaning we do it because it comes naturally to us. And if we thought it was a bad idea to do what we do, we wouldn't probably do it. So we probably don't think it's a problem. Like my sarcasm back in the day, I didn't think it was a problem. I thought it was pretty funny. I was wrong, but that's what I thought. And I did it because I thought it was fine. And it turns out other people had to tell me otherwise.

which I listened to and I changed that aspect. It's not gone 100%, but I've suppressed it pretty well. I can recall as a program director talking to some residents at different ones over time, like, you know, this is how people are seeing you. This is what the nurses are perceiving.

Are you okay with that? Because most of the time people are horrified to find out what they find out. And they're like, oh, no, I don't like it that way. And then you're like, okay, so if you want it different, this is how you have to do some different things. And this is what that could look like. On the other hand, if you're like, yeah, that's fine by me, then you're good. Then your brand is consistent with something you're comfortable with. But I have had people...

Decide that what people are branding them as or thinking of them as is not how they want things to be. And then they have to decide what specific changes they'll go. They'll enact in their day to day activities to to change that brand somewhat. Yeah. How do you recommend people go about building trust, becoming a really a trusted colleague for those around them? I think.

It's a long-term process, meaning nobody gives it to you. You know, I was joking about the EF Hutton commercial. They say something about, you know, we get trust the old-fashioned way. We earn it. And I think anesthesia providers are the same way and healthcare providers in general are that way. It takes months, years of daily behavior and decision-making and, you know,

caring for patients effectively for trust to be delivered. So I have a story I tell trainees that back when I was a resident, people would lean up and go, hey, anesthesia. And they were trying to talk to me. I'd usually grab a bottle of foreign and go, this is anesthesia. I'm Keith. Which one did you want to talk to? And they usually quickly apologize. And I'm like, yeah, just to say I'm Keith. And they would get it, not do it twice.

But the idea was that I was just the resident. No one knew who or what I was. And then after time on faculty doing a lot of the more difficult cases and challenging cases and providing, I think, good care most of the time, the attending surgeon started calling me Dr. Baker. And I thought, well, that's really weird. They used to call me anesthesia. And I wondered for a couple of years, what is that? And I didn't know, but then I realized –

They find me useful. And in their domain, in their social hierarchy, calling somebody a doctor is their way of saying, you know, we trust you. We have confidence in you. And so I decided that that was okay, meaning I wasn't going to correct them and tell them to call me Keith because in that social order, that's actually useful. And so...

I think what happens is once you fix a bunch of clinical situations over time and they see that, they realize that, oh, this person's useful.

and can fix the problems that happen in the operating room, can get us out of dicey circumstances every now and again, they develop a confidence and a value of your presence. And that's the origin of it. So it's a very slow, slow process. It takes numerous management of circumstances that are suboptimal where you get out of it in a good way that I think allows them to start to trust you

because they've seen it happen again and again. So I think it's very slow. And in my case, I think it's because I was very, very focused on developing excellence in patient care. I was never really bothered about what the surgeons thought, but I was very bothered about wanting to know what's the best way to take care of this patient, what are the best moves to make when X, Y, or Z happens, etc.

And reading a lot of literature so that my confidence in my decision was there for me. And whenever going, I'll say, toe-to-toe with the surgeon about a difference, I had game. I could cite the papers. I could say, well, here's why, and here's the papers, and I'm happy to share them with you. So they realized I had something that I brought that was of use to the OR, which is where I think the trust develops.

Fabulous. Well, Keith, we've covered so much great stuff. Just a goldmine here. Anything we didn't cover that you want to mention before we move on? No, I think I think a lot of what we touched on this is pretty useful stuff. I'm sure I got to say it's all there's so many facets to to doing what we do. And, you know, today, this afternoon, I'm sure I'll think of some other things I wish I said because they're so valuable.

I'm sure of it. Well, we will do a part two anytime. So keep notes of things you realize you wanted to say and we'll have you back on. Let's turn to the portion of our show where we make random recommendations. Do you have something you'd recommend the audience check out for fun? I do. Sure. I have a lot of, like I said, I read a lot. I read usually at the current time.

motif we've been talking about is clinical excellence. And so the person that really sort of, I think, has framed up the concept of expertise and superior performance is a guy named Anders Ericsson, who's passed away a couple of years ago, unfortunately. But he's the granddaddy of expert performance and the whole concept of deliberate practice. He wrote about it. He studied it. He's written books about it.

And he has a book titled The Road to Excellence, the Acquisition of Expert Performance in the Arts and Sciences, Sports and Game, which he published back in around – let's see here if I can find the year –

1996. So it's an easy read because it's actually written for folks who aren't at the original literature level. He's got other books, too. One that I recommend possibly for the more interested or eager beaver is the Cambridge Handbook of Expertise and Expert Performance, edited by Anders Ericsson and others. That's in 2018. But these books are fairly fun to look through, and they deal with –

how all kinds of different people in different domains utilize very similar strategies to become good at what they do. Fabulous. Well, I, um, I,

I think that's a great book that I know of Erickson, of course, but I don't think I've read that book. So I will check it out. I'm going to recommend and I think I may have already recommended this, but at the time I was early on in it. And now I'm on the final of 12 books in the series called The Cradle Series by Will White.

It's a really just fun, if you're looking for a fantasy series that is just totally get you out of the real world and into kind of a fun, interesting, easy to read, page-turner universe, I recommend it. There are 12 books, but as I think I mentioned before, they're short. So each book is maybe about a third the length of a long type fantasy book. So it's probably more like four longer books.

But they really read fast. And as I said, I'm on the 12th and final one. And I could say it's panned out to be fabulous. So I'll recommend again the Cradle series by Will White. And White is W-I-G-H-T. All right. Keith, thank you so much for coming on the show. This has been fabulous. And I'm really grateful to you for taking the time. Thank you very much for the opportunity to speak with you, Judd.

All right. Hopefully you got as much out of that as I did. That was really fantastic. Let us know what you thought. Go to the website, akrak.com, where you can leave a comment. Others can learn from what you have to say. If you are a fan of the show, you can follow us. We're on Twitter. We are on Facebook. We are on Reddit. And we are on Instagram.

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