I just had my first clerkship evaluation (I concluded a month of inpatient pediatrics yesterday) and was quite taken aback to hear from my attending that the residents I worked with found me “too enthusiastic.” The examples they gave: when both the resident and I were talking to parents, I would interject or explain stuff after the resident had already talked. The attending told me that SHE thought the situations they described were “entirely appropriate behavior” on my part, but that I needed to be aware of how my actions were being interpreted by the residents. She presumed - and she was right - that since I probably had spent more time with the parents, I had a better idea of how to best communicate something to them - and that was why I elaborated on things a resident said. That is correct; I also found that the residents used medispeak - e.g. “keep him well hydrated” instead of “encourage him to drink lots” 
So I spent all evening pondering this. I am 46 years old, which counts for something as far as life experience. (I hope.) In addition, I have experience as a parent which I know is helpful in talking with parents of sick kids. So I came across as quite confident and self-assured in pediatrics - and this was a negative!!!
I am feeling just a little bitter. Reading between the lines of this feedback, I conclude that not only am I supposed to figure out how to care for my patients, but also how to be mindful of my residents’ feelings - 
Seems like a learning objective that is probably not on the evaluation sheet…
And that last comment sounds like a huge whine but I am feeling extremely exasperated at the moment. The other criticism from the residents was that I had been rather abrupt in shooing a mom and sibling out of the treatment room when we were trying to start an IV on a kid whose dad was with him. WELL. This one really pisses me off, because I have seen these same residents discourage parents from being in attendance at procedures all month; I have heard them mutter under their breaths about having moms or dads in the room; I have heard them basically tell parents, “It’s better if you don’t come.” But when I kick out a mom whose 2 y/o is pushing a stroller around a small treatment room I get nailed for it???!!! I would have thought that I’d get a thank you for that. Sheesh.
I should say - before someone responds “obviously your residents were jerks” - that I enjoyed working with these residents, I learned a lot, and my overall experience was very positive. I am disappointed that they didn’t have the balls to bring up their concerns about my interjecting in their conversations with parents. And this brings me back to my frustration about the age difference between me and your typical 27 y/o PGY-2: it is a lot to expect that a new young physician (whose work experience is likely severely limited) would be comfortable giving negative feedback to a student, especially one who isn’t acting like she is clueless and in need of constant direction.
But it is also a lot to expect that I should have to be cognizant of a residents’ feelings in addition to being sure that I am giving good patient care.
My big sib, who’s older than I am, has encountered this and calls it “age discrimination.” I dunno if that is the right term for what I heard yesterday. It’s more like, "Medical students have to be in a particular mold for the residents to work well with them. Deviate from that pattern at your peril."
I’m not even going into the many times I kept my mouth shut because I learned that doctors weren’t interested in expertise I’d acquired outside of medicine (I used to be a board-certified lactation consultant, and physicians don’t know squat about breastfeeding, but on the few occasions when I said something they looked at me like I had two heads).
This is pretty frustrating. I can do it but I am not happy!
OTOH it has given me some thoughts about the project I’ll have to do later this year and into senior year. There are several GW faculty members interested in medical education and I’d like to take my frustration and see if some good can come of it - right now it’s an amorphous concept just percolating but I hope it’ll go somewhere.
anyway, sorry for the whine but it was sure frustrating to go through the rotation thinking, “Wow, I am doing a good job of talking with parents,” only to find out that I got dinged for it. 
Thanks for listening!
Hoo boy, am I ever connecting with you on this topic…
There's a real phenomenon in medical training of 'junior members (medical student/resident/nurse/etc) should be seen and not heard'. ESPECIALLY in the matter of family communications, medical personnel - who are doing their best to navigate through complex situations, fraught with intense emotions and sometimes irrational behaviors - simply resent the intrusions of less experienced team members, who may-or-may-not hold actual insight into the situation.
As more mature learners, our age and experience allow us a level of confidence that traditional students often don't demonstrate. Subsequently, we do find ourselves more often in conflict with senior members, or at least with strong opinions which we feel we have a right to express.
Now, as Hanz and Franz would say, hear me now and believe me later. I promise you, when you become more senior, there will come a time when a junior member working under you will display some of the same behaviors that you've just talked about. You will feel indignant and annoyed at their presumption, you'll recognize errors in their judgment which their inexperience hasn't allowed them to appreciate, and worst of all, you'll squirm in the uncomfortable recognition that YOU were just like that when you were at their level of training. You'll then fight the impulse to immediately telephone your old residents and staff and beg for their forgiveness.
Teasing aside, there's another side to these stories you relate. For instance, requesting family members to leave during a procedure is a highly charged matter. One inflexible policy (always leave or always stay) isn't going to allow the best outcome, so typically physicians tend to make these decisions on a case by case basis. Perhaps, due to your inexperience, you failed to recognize the dynamics of a contentious, defensive family, already suspicious of medical personnel, and the efforts of the medical staff to comfort and appease them - in part by bending their usual rule about being present for procedures. If your staff was pissed enough to carry this event over into your evaluation, then my guess would be that, unbeknownst to you, the family went on to lodge complaints (or god forbid - a lawsuit) against the medical personnel involved with their child's care.
Do I sound like I'm talking from personal experience? Boy, you got that right.
My advice - and I wish I'd been smart enough to see this earlier myself - would be to lay a little bit low at first. Get some experience and perspective under your belt before you start inserting yourself into the very delicate balance of patient/physician interaction. You do have tremendous gifts to offer stemming from your background, but make sure you understand the subtleties of the existing systems before you charge into trying to change them. Believe it or not, lots of these same residents and physicians are also moms/dads, previous RNs or social workers, or however else you look to classify the more sensitive side of people. Sometimes these situations are happening for reasons which are not quite clear to you - but will be someday.
Sorry to sound so preachy. But my path probably would've been a lot smoother if someone had given me a cold slap in the face early on. I sure needed it.
Cheers!
My dearest Mary - welcome to the somewhat paternalistic side of medical training. You will not only experience this with the occasional resident, but also with a few attendings along the way. I could wirte a short book chapter on the BS I’ve had to learn to cope with under this very topic.
1 - frequently being the eldest male, the patients direct their answers to me instead of the residents…esp touchy when the occasional female resident takes offense. As a general rule, it is laughed off, but there have been some ruffled feathers over it!
2 - I also find myself knowing more about running ventilators and appropriate resp treatment modalities than my supervising resident and, frequently, the attending physicians. If I have had the opportunity to establish my credibility, I have no problem and am frequently asked for my advice. However, I have come across more than one resident & attending (one’s even a pulmonologist), who ascribe to precepts long abandoned or genuinely do not know, who are quite offended by a mere medical student offering treatment recommendations.
3 - Two particular attendings, it takes all I can to bite my tongue here, have taken to asking me ever escalating questions trying to expose my lack of knowledge in front of other students or residents on resp topics. when rounding, there is no way to avoid being the target - so I answer to the extent of my knowledge and concede when what they wish to know is beyond me. On numerous occasions, when they cannot “stump” me…these two bozos have resorted to telling me that my final answer was incorrect and then regurgitating my own answer to the other students/residents as if it were their own. Of course, the others have to fight to avoid snickering cause they know that Joe-Schmoe attending just displayed their ass in all its glory. Try showing up the attending inadvertently for a little discomfort.
4 - on one of my evals, by a resident, he marked me off for being “too comfortable and too informal with the patients and their families” in pediatrics no less. He did not like it that I did not make them call me “Doctor Kelley”. I am not a physician yet and have learned over many years of experience in pediatrics that a measured degree of informality, judiciously applied, yields a degree of trust and self-revelation that you will not get if you portray yourself as God-Physician with a stick up your ass.
Fortunately, this sort of stuff has been exceedingly rare for me…but is a real issue. I have had to learn that discretion can be the better part of valor (keep my mouth shut). I generally do not reveal my professional experiences until asked or I feel comfortable that I will not be grilled for it. I choose to not answer some questions that I know the answers to to both help my colleagues in their learning (let them think through the process) and to avoid being targeted by a few assholes. I have mastered the appearing as though the “light bulb has come on” look when I have grown fatigued at watching someone who truly does not understand something try to explain it while maintaining their aire of false-superiority.
Just remember that you have been doing this stuff since that resident was likely still pooping in a diaper. However, you must also acknowledge that he/she outranks you and inadvertently “showing them up”, even though your intentions are golden and the perceived malice completely erroneoous, will not be appreciated. You have to learn to hold their hand and encourage them w/o appearing to hold their hand. Sorta like raising your kids when they began approaching their teen-years I would imagine.
See, now this is why it is so nice to have this forum. Other people’s suffering becomes my learning experience!
I wonder if being a former nurse doesn’t actually make this more difficult–since you weren’t being supervised by doctors but rather, working as part of the team, you may be used to more autonomy than you get when you’re working under someone. This kind of contribution–translating medicalese, reassuring people, getting people out of the way–was your job, and what was expected of you. It is the essence of the nursing role and the nurse’s best instincts.
But I know that when I was directly supervising people in health education work, I had a different attitude about this sort of thing than when they were part of the team and supervised by someone else. If it was the latter I could have a bit more of a collaborative attitude and accept that we were working together to accomplish a goal; if they were working for me, anything they said in addition to what I said was my problem and hence automatically caused me anxiety and often, annoyance–even when it was helpful.
However, since part of what I was training my trainees to do was to communicate, I also tried to make opportunities for them to do that. Are you getting those opportunities? Is the lack of chances to talk to patients on your own terms contributing to you stepping up when other people are up to bat?
In the defense of the residents, I think that even if the person in charge of communicating a message is digging their own hole, it is their hole to dig. And it’s sometimes better to have one message that is badly articulated than several messages, even if yours is better articulated.
But, I am absolutely sure that this is going to be one of my struggles when I get to the clinic. I imagine that any of us who were health workers of any kind will have an especially hard time with this. I’m going to face it whenever doctors talk about behavior change or sexual behavior with their patients, because I already know that many doctors approach these topics in ways that are somewhere between simple-minded and outright counterproductive. (A sexual history as taken by one of my doctors when I was a patient: “Heterosexual?” The answer was clearly supposed to be “yes” which was then going to put the whole awkward topic to rest. Clinic location: less than a mile–a direct short bus ride–from the world’s best-known gay neighborhood.) In fact, even before your message I was thinking about how I was going to face this challenge. I’m kind of thinking that residents and docs where I’m headed aren’t going to typically be the “I like getting my students’ helpful input” types.
For me, I’ve been thinking that I am going to try to approach the whole process like an anthropologist. Anthropologists make a studied effort to act ignorant so as to draw out the rules of the game as the members of the culture under study understand them. The anthropologist then reflects on those observations and tries to understand the logic and impulses behind them, without necessarily accepting the culture’s ideas. But, reading your post, Mary, made me think that might be easier said than done. I’d be curious about what strategies other people have used.
cheers
sf/dc joe
ps–do you know what your final grade/evaluation for this clerkship will be like? Is this going to actually hurt you or will the attending end up writing you a good eval. anyway?
Lots of good food for thought; thanks everyone! As with any hurt, this one is stinging less as it grows old. I may inwardly rage against having to play this silly game, but I can do it. Dave, I felt a lot better reading of your experiences - I have already had many of the same. (keeping quiet when I know the answer; asking a question of an attending when I DO know the answer, etc.)
GED, you make a good point - one I normally keep foremost in my mind - that just because someone is young doesn't mean that they can't have had significant experience that has a big impact on what they do. I have occasionally gotten impatient with OPM colleagues who speak dismissively of the young as if that automatically means they hadn't had meaningful life experiences. One of my young classmates actually started school the year before I did but had to withdraw when both her mother and brother were diagnosed with cancer; her mother died several months later. So thanks for the reminder!
To answer your question, Joe, I have no idea what this will do in terms of my final grade. I am quite sure I'll pass, but I would be lying if I didn't admit that I would like to get some clinical Honors grades. If it doesn't happen this time I will have lots of other opportunities; I'm not going to worry about it.
Mary, hang in there! It's all a learning experience and I'm sure as you move up the proverbial 'food chain' you'll gain new insights and new perspectives. I like the anthropology approach Joe will implement, I was chortling over that one. GED2MD and Dave give excellent commentary and advice. Just go with the flow. Best regards, Vita (Big Hug for you).
| Quote (Mary Renard @ Aug. 03 2002 11:07 am) |
| I just had my first clerkship evaluation (I concluded a month of inpatient pediatrics yesterday) and was quite taken aback to hear from my attending that the residents I worked with found me "too enthusiastic." The examples they gave: when both the resident and I were talking to parents, I would interject or explain stuff after the resident had already talked. The attending told me that SHE thought the situations they described were "entirely appropriate behavior" on my part, but that I needed to be aware of how my actions were being interpreted by the residents. She presumed - and she was right - that since I probably had spent more time with the parents, I had a better idea of how to best communicate something to them - and that was why I elaborated on things a resident said. That is correct; I also found that the residents used medispeak - e.g. "keep him well hydrated" instead of "encourage him to drink lots" anyway, sorry for the whine but it was sure frustrating to go through the rotation thinking, "Wow, I am doing a good job of talking with parents," only to find out that I got dinged for it. Thanks for listening! |
Hi Mary,
Those parents were fortunate that you took the time to explain some of that "medispeak". I really get the sense that your residents were perturbed that you remembered to put instructions into language that the patients could understand when they didn't think of it. You also suffered the slings of a most likely younger resident who resented your natural ability with patient care. After all, your nursing experience gives you several years on him or her, which is pretty discomforting to some residents who are feeling that they must be acknowledged as "the boss" in every situation.
I do think that you need to bring this matter to the attention of your faculty education committee. This needs to be taken care of as soon as possible. The biggest problem with clincal evaluations is that they can often be very subjective. I certainly hope that you have a chance to evaluate the resident too. At Howard, evaluations went both ways which generally helped your final grade.
Don't be gunshy on your next rotation. You can take this one subjective evaluation as information to be tucked into the back of your mind.( Remember I am living in a world where the average educational level of my patients is fifth grade!) I have to explain things over and over for many of my patients. I crave a medical student who is willing to spend some time reinforcing what I am trying to convey because I have to move pretty fast especially in clinic.
When I was a third-year medical student, I also made a habit of having a five-minute talk with my resident about 2 weeks into each rotation as a performance check. Is there anything that I should be working on? Do you have any advice as to getting this material mastered? I really hate the GW system (we have had this conversation with Cathy) because it does set you up for a torpedo job if the resident is in a bad mood.
With the medical students on our service, I try to give feedback immediately. I had to have a short conversation with one of the medical students who came into an exam room and began to critique the way I filled out a history form in front of the patient, a very nervous lady in a breast cancer clinic. She didn't get my hint when I told her that it was OK. She picked up an inpatient history form and shoved it in my face and told me to fill it out because the patient might be going to surgery all in front of the patient and totally ignoring the patient who was clearly becoming upset at any mention of surgery. This medical student had the idea that since she was highly ranked in the class, she could point out flaws in my history-taking. After all, I graduated from Howard, a school that is low ranked!
When I got outside the room, I wanted to strangle her but I calmly told her that medicine goes on inside the room and that clerical policies go on outside and certainly not in front of any patient. The medical student ran to the resident to tell him that I had corrected her behavior and surprise, he backed me. When it comes to making my patients uncomfortable, I would have thrown her out of the room before I let her upset this patient any further. She is young and pretty unsympathetic to the patient. Needless to say, she didn't go in on any other history session with me that day. It was all I could do to keep my anger in check because I was the one watching the patient almost tear up as she ranted on and on about an inpatient history form.
Listen to what your attending says and take the resident's comments under advisement. Don't back off unless you note something in your behavior that you didn't realize was there. Believe me, I never realized that I can become flaky when too many people hit me with different things at the same time. I often find myself telling folks to go one at a time because my brain overloads fast. A great chief resident on my senior medicine rotation pointed that out. Even to this day, she has influenced my approach to practice far more than she realizes because she took the time to go over a thorough evaluation with me pointing out my good points and bad ones too.
Shrug this one off Mary and head into your next rotation with a head of steam and refreshed knowing that one rotation is in the can and you are closer to that MD. I, for one, suspect that your peds resident already knew that you are on your way to an outstanding career in medicine and couldn't understand how you could be so advanced at this point. Remember, you are supposed to be scared out of your mind
. Nat
Nat, thanks for an excellent pep talk - I’ve printed it out for future reference! When you talk about evaluating residents, and getting together with your resident about halfway through, I realize part of the problem with this month was that the resident picture was always changing - they were on a different schedule from us. So while I was generally on call with the same resident, during daytime work hours I had four different residents I might work with. They were all PGY-2s which means just a month out of intern year and a little unsure of themselves as the “chiefs” for the floor.
I would have slapped that medical student, too. I am quite sure that I did not say a single thing that contradicted or confused anything my resident had already said - though maybe they felt I did, I dunno. I’m not going to worry about it!
Now I get to luxuriate in a month of outpatient, where there’s no call and office hours start at 8:45 AND the office I’m working in is 10 minutes from my house - couldn’t get any sweeter than that!
THANKS! I do believe I have “shaken it off.”
Hehehe…
I can’t help being struck by the irony here…how a slightly different vantage point leads you into an entirely different perspective.
Somehow, I suspect that this medical student is on some website somewhere, or at least having tearful conversations with friends, somewhere along the lines of…
…nurse asked me to have Dr. Belle look at this paperwork…
…just trying to help out…
…so unfair…
…just doesn’t like me because I go to XYZ medical school…
…absurd contention that a woman with a breast lesion sitting in a SURGEON’S office is somehow unaware of the possibility of surgery…
…could just as easily have handled the situation gracefully by saying, “thank you, Beth. I’m in the middle of conversation just now. I’ll take a look at that with you when I’m done here” instead of being all cryptic, turning it into a big deal, and making me feel terrible…
and so forth.
I’m probably stirring up a little bit of a firestorm here, but I just wanted to make a point.
This medical student is YOU, Mary, and YOU Nat, and ME. And all of us are - on occasion and in the eyes of our underlings - those wicked, unfair supervisors.
There’s a little bit of tendency on this website to polarize people into catagories, as though all residents/physicians are these souless children with no conscience, who somehow bribed their way into medical school. And we, the people on this website, are these genuine, spiritually fleshed out people, seeking to bring the only possible shred of humanity into the practice of medicine. And yes, I realize that I do this too.
Although I’m 39 years old, I look very young, and most people assume I’m in my 20s and simply on track for my education. So I do catch a lot of this attitude on occasion when I’m dealing with other nontraditionals. It’s easy for me to see both sides of this fence. Consequently, I’ve been TRYING to get better at stepping back and seeing from the other person’s perspective. Usually the truth (if there is such a thing) lies somewhere in the middle.
I doubt this medical student is some evil, academic snob who ‘deserves to be slapped’. She’s probably a decent girl with a good work ethic and good intentions, struggling to find her way in a new environment.
And those residents - probably not ‘jerks’ - but folks just like us, trying to do an overwhelming job and appease a lot of different people’s needs simultaneously. Mom’s need to stay in control and ‘protect’ her child; your need to be a part of the medical team and grow as a physician-in-training; their own need to maintain authority and credibility as young doctors; and the child’s need for medical care.
Just some food for thought.
Cheers!
GED2MD I do love your being the devil's advocate approach. I do think that we all need to be aware of other folks perceptions regardless if it goes against what we would do or think that should be done. I am still pre-med but find this rampant among non-trads, thinking that the younger pre-meds have a lot to learn, yada yada. This may be true for some young folks but I sure have met many younger people that are mature beyond their years and already know what path they would like to pursue. I was nowhere within that attitude in my younger years! So I love to surround myself by younger folks, most of them I have found to be truly amazing at such young age. I have also found some non-trads that assume that just because of experience they have the right to certain things…so, I guess inmaturity can go both ways. Sorry to have gotten off on some tangent, but your comments brought home many of the great and not so great things that I encounter with both ages groups.
Mary,
I am currently half way through my peds rotation (also 6 weeks). I have also completed my OB/GYN rotation as well. I have learned over these past weeks that the physician always wants to be in charge; it’s almost an ego thing. So therefore, I don’t speak until spoken to most of the time. When it comes to speaking with the patient & family, unless it is my turn to lead the discussion, I let the physician do all the talking. Of course there are times that they want me to be in charge & talk and then they interject when appropriate. I have also learned that when I go in by myself to do my H&P (which is most of the time, unless we are busy), I will start my discarge teaching before hand. That way, I get in the “nurse info” that sometimes doctors don’t think about, that way I don’t step on any toes.
I also will not tell my residents and staff that I am an RN. They treat you differently. “You already know that,” when in actually I may not. My fellow, younger classmates, feel that I have any unfair advantage. They feel that I will get a better grade than they, so they volunteer that information, even when I ask them not to. Although when I throw in an IV on a patient that is a hard stick, or I walk comfortablely around the hospital or the patients they tend to figure out that I have had some hospital experience.
I have done exactly as Dave has done, and not said a word even though I know an answer is wrong. It is not my place as a 3rd year, no matter how much experience that I have. And I have acted as if that is a brillant dx & treatment plan, even though I knew the answer. I know that sounds wrong & and I should stand up for what I believe is wrong. But I have not had an experience where it meant that much to me or to the patient to correct or add to a resident or attendings assessment, diagnosis, or patient education. If it was important, then I would say something, of course, never in front of the patient. I don’t think that it makes me a weaker individual, I think I am just choosing my battles.
Rachel Wankum
MS-III, CCOM
There are really two issues here, and it's important that we not confuse them.
Mary got called on the carpet for intruding (inappropriately - they felt) into patient-physician interaction. Again, this area is a potential land mine, and it's often difficult for the inexperienced to appreciate how quickly and how dramatically things can go wrong.
We've got two good examples of how a rookie, a smart person with good intentions, can get into trouble. Just a couple more years of experience let Nat see how diverging into a clerical discussion in front of an emotionally fragile patient was not helpful; and Mary shooed a mother out of a patient's room either in a way or in a circumstance which others felt was harmful. Even though all of us believe in our heart-of-hearts that we are the Mother Theresa of patient interaction, it's good to defer to experienced team members until we better understand the lay of the land.
With regards to MEDICAL KNOWLEDGE, I firmly believe that everything is free game. Obviously you need to practice tact and good judgment, and as Rachel points out, when dealing with insecure people you sometimes have to choose your battles. However, it is critically important to foster an environment of evidence based approach. Medical decisions need to be based on science, and every person of the medical team has experience and knowledge to offer.
Without being confrontational, if you disagree with a point, try to enlist a discussion. My staff have learned that, if they argue a point with me, I'm very likely to show up the next morning armed with a stack of journal articles in support of my opinion. This is the essence of a learning institution, and overbearing, easily threatened people are wrong when they attempt to squelch these activities.
That's my 2 cents worth (SHADDUP already, would ya GED!)
Hey Folks,
I am post call so I may get somewhat flaky in this post. Bear with me My brain needs just a tweak more caffeine! There is a tendancy among medical students, and I was no exception, to be oriented toward getting the “medical student tasks” done. This medical student that I very calmly admonished was more interested in me getting the H & P done than in what the patient had to say. It isn’t difficult for me to put myself in the place of a 50-year-old lady who has been relatively healthy, possibly getting the news that breast cancer is on the horizon. The one thing that my Breast Surgery attending places great emphasis in his teaching, is sensitivity to the needs of his patients. That is why he can have a thriving practice, in the middle of a very small area and do nothing except breast surgery. He is very, very good with his patients. He is also a very young male surgeon (38 years old) who is building quite a reputation for himself. I make no apologies for admonishing that medical student who found the need to admonish me, in front of the patient, without regard for the patient’s feelings. I was the one who calmed this lady down, along with the attending, after we discussed her mammogram findings which did not indicate a need for surgery.
I will never like the subjective evaluations that residents are required to make of medical students. I generally do not hand out poor grades unless a student refuses to participate in patient care. Most medical students are pretty motivated types who need to be restrained rather than prodded. Often this high motivation to “just get the work done” comes at the expense of the patient. I spent most of the day in melanoma clinic yesterday listening to my three medical students whine about how tired they were. I eventually told them to head back to the main hospital, get some rest and do some reading. The whining was getting on my nerves and they were not very helpful. At least they could salvage the day and get some book knowledge. That left me and the attending to finish clinic. I missed my journal club but I learned lots about melanoma and good patient work-ups.
Morale of the story for medical students: Don’t whine to your intern about being tired. You are preaching to the choir 
While I would have loved to have had some help, I couldn’t stand the whining.
Not only did I have to finish clinic, I had to get sign out from the interns on Transplant, Hepatobiliary and Plastic Surgery services. I was up all night checking the capillary refill on skin flaps and keeping a septic patient alive. She’s in the unit now. I have Day Call today for my own service and we have a full contingency of cases posted along with a patient who left the unit so there was much to do in getting him settled on the general surgery floor.
Nat
Mary,
I forgot to add this to my reply…
it sucks what they did to you. It's too bad that these residents were not secure enough in their roles to be able to accept the expertise that you have brought with you.
Good luck with your next rotation.
Rachel
| Quote (GED2MD @ Aug. 06 2002 8:02 am) |
| We've got two good examples of how a rookie, a smart person with good intentions, can get into trouble. Just a couple more years of experience let Nat see how diverging into a clerical discussion in front of an emotionally fragile patient was not helpful; and Mary shooed a mother out of a patient's room either in a way or in a circumstance which others felt was harmful. Even though all of us believe in our heart-of-hearts that we are the Mother Theresa of patient interaction, it's good to defer to experienced team members until we better understand the lay of the land. |
WITHOUT, oops caps on, being on rotations, with regard to the managerial issues expressed here, Nat's underling was abusive and arrogant.
I do not think that Mary, while she is a strong personality, was acting in that accord and I do not think the two are remotely related. Nat's Med Student deserved a failing grade on that rotation for that act of arrogance IMO. She was rude, abusive to the Doctor in charge, and possibly frightened a patient. It takes a massive ego and a condescending attitude to do what she did. Not many students of any age would do what was demonstrated there.
I think Dave posted a few well thought out methods that seem to work most of the time for him, but if someone is out to get you, there is simply nothing you can do except try and deflect it with wisdom and charity.
Oh…some other things I wish I had included in my original reply:
One, understand that the residents & interns that you will be working with will usually have far fewer years of clinical experience than yourself, esp folks like Mary Nat & myself. However, also recognize that even though we have far more years of patient care, that our perspective is that of an allied health professional, which is different than as the physician. I am in no way defending their actions, but pointing out that there are nuances that we have yet to learn about the role of “physician” and that there are also nuances that they have yet to learn about said role and interpersonal relations. The ideal situation is to establish rapport with them, when ever possible, and to teach one another from our own bag of skills in a professional, non-confrontational manner.
Two, a very effective manner I have learned to both establish my clinical credibility and simultaneously inquire about an action that I do not understand or feel inappropriate is the good old fashioned question & answer format. I begin from the perspective of legitimate inquiryabout why and how the treatment decision(s) were made - after all, that is my primary responsibility as a med student: learn when, why & how we do the things we do. In the process, as I learn the impetus behing the choices I am questioning, if I learn something new and that I was indeed incorrect – then I chaulk it up to a new experience and do my best not to forget it.
But, if I continue to feel that I have something better to offer, I begin to lead the conversation through detailed questions that include background info supporting my own suggestion(s) & gently lead them to my own conclusion. Usually, in the process of doing this, if I my solution was a better one, they figure out several things: 1 - that I have some background knowledge, 2 - I’m no dummy and they usually inquire as to my background & 3 - are genuinely appreciative of my suggestion for enhancement of patient care.
Using this tactic allows for a non-confrontational exchange of information that provides for teaching to both parties while avoiding “challening” thier authority. I do not do this in front of others, esp patients, to further avoid the potential of insecurity or ego tainting the process. So far, it works very well for me. I have learned a ton this way and have earned the respect of the vast majority of the residents & attendings I work with in this manner. I have even had several of them tell that they appreciated and admired how well I handled the exchange and wish that they had figured out such a tactic when they were at my level. I just explain that away by stating that sort of shit comes with being an old fart.
Great, HELPFUL advice on navigating our way through the maze of on-the-job interpersonal interactions, Dave.
For, although Mary jokingly commented that she didn’t realize that figuring out ‘how to be mindful of my resident’s feelings’ was a learning objective likely to find its way to her evaluation sheet - actually quite the opposite is true.
The American Graduate Medcial Education Committee (ACGME) just instituted mandates for what they are calling ‘core competencies’. These are competencies which MUST be demonstrated in order for your residency program to graduate you, and it extends across all residency programs (medicine, OB, surgery, etc).
A small part of the competencies includes knowing how to do an H&P, demonstrating diagnostic skills, certain procedural accomplishments, etc. However, the majority of the competencies have to do EXACTLY with just what we have been talking about: working effectively as part of a larger medical system.
Categories exist such as ‘Interpersonal and communication skills’, "Professionalism’, and ‘Practice based learning and improvement’, measuring such intangibles as ‘listening skills’, ‘creates therapeutic relationship with patients’, facilitates learning of others’, and so forth.
Measurement tools involve questionaires for RNs, respiratory therapists, social workers and pharmacists, inquiring, “does this physician illicit input from ancillary personnel?” “Does this physician explain when there is a divergence of opinion regarding patient care?” "Is this physician available to you with regards to patient care concerns?"
Medical students and junior residents are asked, “does this physician foster an environment conducive for learning?” “Does this physician interact with you with respect and concern for your emotional well-being?” "Does this physician display sensitivity to cultural, age, gender, and disability issues?"
Patients and family members are asked, “would you refer a family member to this physician?” "Was this physician a good listener?"
There is a lot of good data out of the airline industry, and some more recently published medically focused data (discussed in last edition of Harvard Business Review, I believe), which support the idea that the best outcomes are achieved when members of teams working toward a shared goal are able to interact free from fear of belittlement or harsh correction.
Airlines reported fewer adverse incidents (like crashes) when support personnel are encouraged to provide feedback to pilots-in-command. Thus, any member of the ground crew, or flight attendent, or whatever is free to express any concerns they may have to the pilot, and if s/he does not hear them out and receive the report graciously, s/he is called on the carpet.
In the OR, better outcomes result when nurses are emotionally safe (meaning the surgeon won’t take their head off) in offering input, eg :“did you realize the patient’s blood pressure has dropped?”, or “why don’t you try this retractor?” or “maybe we could set the room up this way” etc.
So, working together as part of a larger system is a very important skill which is actively being measured in medical training now.
And, by the way, like everyone else, I think Mary showed enormous emotional intelligence in dealing with her residents, who are - just like the rest of us - also struggling to master these same skills.
Regards!
THANKS for all the thoughtful feedback. I have really enjoyed reading everyone’s ideas and viewpoints. Under normal circumstances I would’ve responded a lot more but (caution: whine alert) I am SICK, have been fighting a lousy cold all week and just don’t have energy for anything. Good thing I am on outpatient now, I cannot begin to imagine what I would do if I were on call.
But I wanted y’all to know I’ve been reading and thinking when I am not coughing and wheezing. (and let me add, it is hilarious to be in a doctor’s office with a cough… I have been offered all manner of free prescription meds from the drug closet in hopes that something will work. Near as I can tell, the old adage that a cold lasts a week without medication, and seven days if you take something, probably still applies - but I am giving the inhaled steroids one more chance.)
Mary, it must have been all those ankle biters that gave you your cold
Get better,
Rachel
Hello everyone, Yes, I've been following this thread with fascination but one thing I've been mulling over and I just want , I guess, more insight into this, is the fact that if you were a nurse in your former life, you keep quiet about it. OK, I understand that your fellow traditional med students may feel like you have a clinical advantage,etc. but is there something more? Are the former nurse med students looked down on ? Is there a quiet, unspoken discrimination against the former nurse, med student? Do they ( trad. med. students, residents, attendings) feel that they're not good enough? I'm just curious especially when Mary mentioned that she was a former nurse to a med student, asked the med student not to say anything and she invariably did. Maybe I'm making something out of nothing but it seems interesting to me that one keeps quiet about having been a nurse vs. someone who may have been a ditch digger prior to med school. If it's just about our advantage in the clinical situation and being modest about that, ok, but if it's something else, how sad. I bring this up so that I and perhaps other former nurses know what we may be dealing with. OK, that said, Mary, summer colds suck! Wishing you a speedy recovery! Vita