Personal Experiences in Interpersonal Relations

sad.gif I just finished my pediatrics rotation and it´s been a nightmare. I was a clinic with only a nurse as medical staff and educator most of the time. Now I love nurses, but is this acceptable medical training? To make matters worse, she actively disliked me and has managed to get me a very poor evaluation. When I tried to discuss it with an attending, she scolded me for not accepting criticism. I am 37 y/o and I filter my criticism, thanks a lot. What the nurse thought about my personality is in stark contrast to all my previous preceptors and attendings.
I was mortified that, in contrast to most nurses I know, she was constantly making tremendous errors with patients. I saved a couple of them to the detriment of my evaluation I guess. She had passed as normal a blood test with microcytic hypochromic anemia due to lead poisoning.
Anybody with a similar horrendous experience? This was my first rotation. Will it get better?

Hopefully at the beginning of third year, your orientation included something about what to do / who to see / where to go if you felt that you had been treated unfairly. You should have had a path sketched out for you, basically 1) talk to the person who is being unfair (e.g. wrote you a crummy evaluation), 2) go one step up the line - this might be the senior resident, the attending, hopefully you’d know the hierarchy, 3) go one step further, the course director, and finally 4) the dean of students or “grievance officer” or whatever might be in place at your school.
At the very least you should be able to provide a written counter-response to the things stated in the evaluation that you believe to be untrue and/or unfair.
If none of this sounds familiar to you… well, shame on your school because they really should’ve covered it, but in any case, since you sound like you’ve already taken steps 1 & 2, talking to the course director would seem to be a reasonable next step.
Find out when the actual written evaluation will be filed with the dean’s office and make sure you get a chance to see it. This past year, some of my clerkships were great about providing us copies and others weren’t - we had to keep checking to see if they’d been sent in. Bottom line, no one cares about this nearly as much as you do and so it’ll be up to you to try and get the best possible outcome from it.
I would stop fretting about the fact that she’s a nurse (NP? it certainly sounds like she was working in an expanded role). A PNP working in a clinic setting could teach any medical student plenty - I worked with PAs and NPs during my primary care rotation and that was never an issue. You might have an issue if you felt that you did not learn anything. (but be careful! course directors don’t take kindly to med students making such assessments, and you can’t blame them.)
But really, her credentials are NOT the issue here. The issue is that you got what sounds like an unfair evaluation from her, and her evaluation would be unfair whether she’s an RN, NP, PA, MD or DO. So sort out your issues here and pick your battles - what do you really want to accomplish? Then you’ll know what to do next.
Good luck - I am sorry to hear it. Interestingly, it was on peds last year that I got kinda nailed by the residents on my evaluation - when i eventually saw what got filed in the dean’s office it wasn’t THAT bad, although I am still scratching my head wondering how I came across as ‘abrupt with patients.’ I think it was because I interrupted a resident who was speaking in jargon. Oh well.

Thanks Mary, I really appreciate your encouragement. What worries me the most is exactly the topic you raise in your response: it is so easy for this to be construed as arrogance on my part that I don’t want to be taught by a nurse, when in fact that’s galaxies away from how I feel. My best friend is a nurse and I myself considered nursing as a career although I finally opted for Med School. I have learned plenty from nurses and count on learning more. With this particular nurse, however, the lines of dialogue were never open. I respected her in so many ways, but the situation was just so wrong.
Like you say, my attending did not take kindly to my comments about my difficulties with the nurse, in fact she was a bit hostile and blamed me, but I am going to comment briefly on these issues when I evaluate the rotation next week. At our age, shouldn’t we be brave to speak up about what is wrong rather than protect our grades?I totally understand what you say about “abrupt with patients”. Why should we accept any and all criticism no matter how outrageous? I think by our age we can distinguish pretty well between constructive criticism and outlandish/exaggerated remarks.
I really regret how this nurse and I miscommunicated.

Also Mary, I forgot to ask. In your primary care rotation did you work with NPs and PA s exclusively or was there an attending or resident nearby at all times to answer questions?

Hi Pilar,
Don’t be put off by your floor learning. Read, Read and do some more reading. You can read a good review book and get what you need for your pediatric rotation. The peds pre-board exam was one of the more difficult pre-boards of third year. Nurse practictioner and PAs can teach you lots of practical stuff but you still need to read up on peds preventive care, adolescent medicine and all of the leukemias that affect pediatric patients.
Learn all sorts of practical things like fluid managment, immunizations, and the things like NEC and the genetic stuff like cystic fibrosis, sickle cell anemia, Henock-Schonlein purpura. Don’t forget things like limps in pediatric patients. Peds is medicine for the younger than 18 set so you can get lots of practical stuff from this rotation that will really help you for medicine.
Learn to put in IVs and procedures. Enjoy!

Natalie cool.gif

Agnes, on the days that I was assigned to work with a PA or NP, we were the team - there was not a resident or attending as part of the team.
I am afraid that I am still not clear about exactly what your problem was with this particular nurse. First of all, WAS she the primary care provider - an NP? Because if so, you do not need an MD/DO looking over your or her shoulder to do primary care. Obviously you learned through a difficult exchange with your attending that the nurse is regarded as a teammate and colleague, and as the very green new third year, you can’t complain about her patient care skills even if you think there are things she overlooked or did wrong. You just don’t have the experience or authority to be able to do that. Reading between the lines of what you’ve related here, I wonder if perhaps she somehow got the impression that you didn’t give her the respect she deserved. Consider if it is possible that you came across that way, and ponder it a bit. Even an innocent question such as “Isn’t Dr. so-and-so going to join us this afternoon?” could be taken as a slight if someone is perhaps a little insecure in their job, or thinks (rightly or wrongly) that you only want to work with a "real doctor."

At our age, shouldn’t we be brave to speak up about what is wrong rather than protect our grades?

Well, it depends. Certainly you were right to speak up about the anemia or other clinical situations you saw that needed attention. As for speaking up if you think you’re not getting the right education - well, there’s an awfully fine line between “speaking up” and sounding like a whiner. As Natalie has pointed out, learning as much as you can during your rotations is entirely your responsibility, NOT the responsibility of your attendings, residents, or others who supervise you clinically. You will have some great teachers, some OK teachers, some mediocre teachers, and some who just can’t even be called teachers at all. But you still have to learn it regardless.
I totally understand what you say about “abrupt with patients”. Why should we accept any and all criticism no matter how outrageous? I think by our age we can distinguish pretty well between constructive criticism and outlandish/exaggerated remarks.

In my circumstance, I just shrugged and thought, “Huh, I wonder how they got that impression,” and didn’t really think too much about it - but I did spend some introspective time thinking about how I might have come across that way. Here again, there is a fine line. It is awfully important to be open to criticism / feedback / whatever you want to call it, because you can learn an awful lot. And you are going to need to develop the skill of figuring out what sort of constructive criticism might be lurking beneath “outlandish / exaggerated remarks.” There may very well be a kernel of truth in there; be prepared to accept criticism even when you are not sure it’s deserved, in case one of those lessons is hidden within.
As for the age factor - be VERY careful! Regardless of your age and life experience, you are a neophyte third year medical student - a “baby” compared to those with clinical experience. Be humble and appreciative for whatever you learn, from whomever you learn it. Don’t ever make the mistake of thinking that your life experience in other venues puts you a leg up on other third years, and certainly not on experienced clinicians - you will really be selling yourself short if you don’t always have your eyes and ears open for how to learn.
My apologies if I have thoroughly misconstrued your situation or been a bit blunt in my response; my BAC is a little elevated at the moment after a particularly fine microbrew (on tap in a friend’s backyard!) called “Alchemy Ale.” tongue.gif

Mary, I do think you have misconstrued my situation a bit and have scolded me a bit extra (and I have had more scolding than I need for one year), when what I needed was maybe some sharing of stressful circumstances? Yet I appreciate your input for what I believe is a touchy topic.
I did not treat this person with disrespect, rather the opposite. But it is true that as I began to see more and more cases of possible malpractice I might have become a bit distant, which is my usual coping mechanism when I don't know what to do. The nurse was also gratuitously damaging other colleagues' reputations behind their backs, same as she did with mine. So I guess it has not dawned on her that she is doing a lot of harm.
I need to come to terms with what to do when I see something as terribly unfair, especially as regards patients. I might need to ponder what is the best course of action. I am right now too hurt to decide what is best.
Let's agree to disagree on the issue of education. A nurse, no matter how experienced, should not be solely responsible for the education of medical students for any extended period of time. Nor should a MD or DO be solely responsible for the teaching of nurses. It's just two different fields. They are complementary, not exchangeable.
As for your experience, you shrugged your shoulders and meditated. That's the adult thing to do. You might have found the shrugging more difficult if you had endured one month of disrespect that included manipulating information about you. Thanks again and best wishes.

It is most truly not my intent to scold and I apologize for my tactlessness.
I am happy to “agree to disagree” regarding the suitability of nurses as educators of future physicians. However, I must add that it doesn’t really matter whether you agree with ME or not - what matters is what is done at your institution! (and I would still be curious to know if we are talking about an RN or a nurse practitioner. As a former RN, I regard them as totally different realms of expertise; in my experience, NPs and PAs, because of their autonomy, have far more in common with doctors than with nurses.) Anyway, if your medical school faculty feels that other-than-MD/DOs can give you good primary care training, and you don’t, this is something you’ll need to discuss further with someone on your faculty.
You may find this discussion (click on the link) helpful. It’s my post from last August, describing my unhappiness at my peds evaluation, and it prompted a really good discussion. Perhaps there is something there that will speak to what you are feeling at the moment… or help you for the future.
I feel bad that I have come across as unsympathetic, because I can relate to your circumstance far better than I even want to explain. On my last 3d year rotation I was so unfairly accused of something so totally out of character for me that I will never understand it or be able to explain it - nor was I able to get to the bottom of it despite a few conversations with some of the people involved. Frankly, it still hurts too much to want to tell the story so I will leave it there… and besides, at this point it is water under the bridge. What did I do about it? I tried to do my very best for the remainder of the rotation and made sure that I was seen as supremely helpful and always on top of things; near the end I had a senior resident ally who made a point to say good stuff about me to the teaching resident. I decided that surely I had racked up enough “good points” to hopefully, hopefully outweigh the bad points. Hope I’m right - I won’t see that grade for awhile yet. But when I say, “I feel your pain,” that is a heartfelt statement.
You will go on and have lots of good experiences this year. You may, unfortunately, have some bad ones ahead of you, too - as near as I can tell, it is the rare, lucky third year who has only one horror story (or none!) to share, unfortunately. But you will learn a lot, you will be strong, you will be a terrific advocate for your patients, and at the end of the year, you will know so much it will be exhilarating! So hang in there, feel bad for awhile then move on and be ready to enjoy your next rotation, 'cause chances are - you will have a ball.

There are a number of issues that could have yielded the problems in your relationship with your supervising nurse…actually, too numerous to even attempt to cover them all. However, working with other health professionals is no different than working at WalMart or Wendy’s - your “team” is comprised of many people, each with their own personality quirks, personal histories/biases & perceptions you, as a medical student. All of these factors serve to color the way she interacts with you…her anticipation of how you will treat her is a huge factor. Add to the mix the fact that you are older/nontrad & interpersonal relations stuff gets waaaaaaaaay complex rather quickly.
I will not even presume to be able to tell you where things went afoul in this particular case. I was not there & could never say for certain. However, as with most relationships, responsibility for things working or self-destructing is virtually always a shared responsibility. Who knows? She may have had a nontrad treat her like shit setting up the anticipation that you may do so as well. All it takes is one potentially off-color comment and your sliding down the slippery slope to discontent.
My approach throughout medical school & now in my residency is to be very cognizant of how & what I say and then measure the person Ia m speaking with’s response – watch the eyes. If I perceive something “not well received”, I try to clarify things then - before the seeds of “hate me” even germinate.
As someone with a number of years of patient care under their belt (resp terrorist for 11+ years + many years in other allied health fields), I have landed in many scenarios where I know more about certain aspects of patient management than my residents (sometimes the attending as well). For example - ventilator management or caring for asthmatic pts.). The tactic I employ is to ask them leading questions. This is especially effective when I think they may be making an error. This serves 3 main purposes:
1 - By asking leading questions I can frequently hand hold them toward what I am thinking w/o appearing to guide them, appear as though I am challenging them or sounding like a know-it-all, pain-in-the-ass med student/resident.
2 - From the content of my leading questions, I can clearly demonstrate my level of expertise in a nonthreatening, non-arrogant manner.
3 - Once you’ve established a Q&A-acceptable situation, then it becomes permissible, even expected, for you to inquire as they why they interpretted x, y & z to mean a, b & c. By doing this, you have transformed things into a teaching environment and therefore can question what has been done or decided w/o appearing as an arrogant, pain-in-the-ass med student/resident.
As with virtually all relationships, your effectiveness will boil down to 4 essential pillars: honesty, communication, trust & respect. All 4 of these must be earned by your…and the people on your team must also earn these esteemable factors from you as well. If you effectively apply these tools, then you can usually avoid relations-gone-bad or the vindictive game that gets played.
Like it or not, you have to be careful & treat all of your colleagues & allied health professionals with respect…sometimes even when you feel that they do not deserve it. By getting too grough with one of them, you can quickly be placed at the bottom of the Christmas card list – believe me, if you’re on the shit-list, those allied health people can make life, esp call nights, realy rough. Simply put, it is best not to pooh-pooh where you eat! And, pick your battles wisely…when you do opt to fight a battle, always strive be as calm, mature & professional as you can be…to do otherwise does not speak well of you or our profession.
Much of my soapbox solliloquy may/may not directly apply to your situation. But, I felt that this might be a grand opportunity to pass along some words of wisdom to you & others who will read this reply.
Feel free to respond with many questions!

QUOTE (OldManDave @ Jul 27 2003, 03:04 PM)
The tactic I employ is to ask them leading questions. This is especially effective when I think they may be making an error. This serves 3 main purposes:
1 - By asking leading questions I can frequently hand hold them toward what I am thinking w/o appearing to guide them, appear as though I am challenging them or sounding like a know-it-all, pain-in-the-ass med student/resident.

Perfect advice, OMD!!!
As a predoctoral fellow in pathology with many years of basic science experience surrounded primarily by resident MD's, ( pathologists, internist) I've found that "leading questions" are the way to go. When discussing topices I feel "expert" at, I'll usually preface my comments/questions with "It's my understanding that x,y,z" or depending on the rank of the person's whose statement I question I'll say, " I'm not 100% sure , but I believe the x,y,z". I also speak in a voice "softer" than the one I speak in when giving a presentation. As much as I hate to do it, I admit that my coments/questions get more mileage than coming off as a know-it-all.
Unfortunately, I had to learn this lesson the hard way in graduate school years ago and believe me, I have the "battle scars" to prove it!
So, I think my grandmother was right when she said that a little dose of humility can go a long, long way. wink.gif

I echo spiritdoc2b & OMD, personal relationship skills are a learned skill. As a MS-0, I can’t offer any expertise on medical issues. However, as a 14 year sales & management veteran, I am continually striving to improve my people skills.
Pilar, you might want to do some reading on the subject. One of my favorite all time books is Dale Carnegie’s “How to Win Friends and Influence People.” I have worn out more than one copy and try to re-read it at least every two years. Additionally, find a book on personality types. There are four major types and most people are a combination of two types with one being slightly dominant. I cant remember any titles, but some use the DISC acronym, others name the types. Understanding what type of person you are dealing with can really help improve your approach and results with them.
People in general love to talk about themselves. Dale C says conversations should be 75% about them, 25% about you. The ability to ask leading question without coming off as arrogant or a know-it-all is a tool that will serve you well for life. Allow people to shine, help make them look good, sacrifice on their behalf and they will be your friend for life. Be a problem solver, someone they can count on.
Good luck with you endeavors Pilar. You can do it!

I think you all guys hit the nail in the head. But especially OLdDave when he talked about anticipation. That´s just it. This person was full of hot buttons and there was no avoiding hitting one simply by being there, being older, and being who I am. When she saw me and knew I had several kids, right then she said “I am sure you know a lot”, to which I replied: “I am really as green as everybody else and have everything to learn.” She used to start every teaching abt infant feedings with “Of course Agnes already knows this”, and in truth I did know it, but the words never left my mouth.
My father bought me Carnegie´s book when I was 10 and I read it right then and several more times. It´s a great book.
Leading questions: I could not agree more. For example, the anemia question I said: Ms. X, I really need your expertise for this. At what values does this clinic start treating for anemia?" At which she snatched the chart from me and circled the Hb values and wrote “anemia”. She said “you are right”. I have always got along great with most people. In fact the receptionist and the clinical assistant at this clinic became friends and said they would miss me. But I have to admit that by the end of the month I was keeping my distance from her, like I said, my usual coping mechanism, and God knows I don’t like being that way, but I do become distant (note, distant, not arrogant). I avoided her as much as I could. My younger classmates were, by their own words, “kissing her up”, but even they received an unfair and crappy evaluation midmonth. By the end, however, she glorified one of them (the one she saw as less eficient for most of the month) to serve as proof that she acknowledged progress.
I am glad it is over and I think what you have in these posts is excellent advice, for which I am deeply grateful.
About people other than MDs having areas of great expertise, I hope I don’t have to state again that I do acknowledge that expertise and feel privileged when it is shared with me. One month ago two paramedics showed me how to intubate and I admired their skill, I am eons away from knowing how to intubate properly no matter how I hard I tried.

Sometimes, you may just have to take the bull by the horns and talk, face-to-face, with them. You know, you may have intended to protray yourself as distant…but, I strongly suspect that if you asked your evaluator, she perceived you as “arrogant & intolerant”. The non-verbal communications for those can easily become mixed or cross-interpreted.
So, what would I do in your situation? Hopefully, I would sensed things early on and simply corrected or clarified my phrasing. If, however, the tension persisted, I would have asked to speak with her in private & attempted to air things out.
With some folks, none of the above will work. Those people…well, you can’t shoot’em; so just chaulk it up to learning experience. No, that does not salve or palliate your crappy eval, but such is life. To be honest, you will encounter these folks in all professions no matter what it is - flippin burgers at Wendy’s or w/i the ranks of pediatric orbitologists…so few of these that there are only 3 to 5 of them in the whole state of Texas!!

Mary, I read the thread with the link you sent and it was a revelation. THAT¨S JUST IT. We do not conform to the mold and people with inflated egos and maybe insecurity will feel uncomfortable, sometimes no matter what we do.
In contrast, people with good self esteem and reasonable egos will enjoy the different areas of expertise for a richer experience. There is a disonance where we are at point m in life experience, at point a in training. Hard as I tried to act like a point a person, the nurse saw me as z and resented it.
I also did not trade my dignity so that I did not play the grade game. I did not tell the nurse how outstanding she was while the other students did. I really did not think she was outstanding, so I could not say that. She refused patients medicaid prescriptions because she said they could get them OTC. But then she would send to the ER someone with an hematoma claiming the arm was broken (and it was obvious it wasn’t, with full mobility of all joints, pronation, supination, and no pain), at a much greater expense. Thus, I did not tell her how super she was, although I expressed to her that I did admire her capacity for work. I was extremely respectful of her, something even she admits. I passed, by the way, just the written comments were very unflattering.
The attending OTOH made a very flattering comment that if she ever was sick and I was practicing, she would go see me. So I guess, while painful, lack of hypocresy is appreciated. I literally told the attending: “I am too old to play the grade game. I am here to learn.”

What on ear blink.gif th is an orbitologist?
QUOTE (Pilar @ Jul 27 2003, 05:51 PM)
Leading questions: I could not agree more. For example, the anemia question I said: Ms. X, I really need your expertise for this. At what values does this clinic start treating for anemia?" At which she snatched the chart from me and circled the Hb values and wrote "anemia".

I don't mean to harp on this thread too much, but I easily see how someone might have taken offense to the wording of the question. I think if I were in this situation I would have worded my questions as follows: "Mrs.X , I'm a little concerned about the value of "X" on this chart. Can you help me figure this one out? This way you 1) acknowledge that SHE is the "expert" in this situation and 2) make it clear that you're here to learn and value her help and 3) demostrate that you're doing your homework
I don't know about you, but I need specific examples of ways to improve my communication skills (and yes, I'm STILL working on it). In grad school we called it "stroking the ego" but I suspect it means the same no matter what you do for a living biggrin.gif

I appreciate your input but, in the context, your wording might actually be more offensive. The reason is that she had snapped several times before to other people," ïn this clinic we start doing (whatever) at… value, or at …age", so my wording was actually following her lead and her previous choice of words. Also, your wording, saying that you are concerned about the value, implies that you do not trust her, as she had already dismissed the test as normal and asked me to file it. I perused it out of curiosity because it was literally the first test I had ever seen, first day of my first rotation, and then saw the Hb and mcv values. What to say? What to say? I frantically pondered.
You see, it is not as easy as it seems.
Also, we do not have the benefit of time to optimize each and every word in a busy rotation. Things happen in real time.
But I appreciate your opinion and it goes to show that perception is everything.
One thing is clear: I knew, at that second, that I had to decide between ignoring the test value or jeopardize my image, and chose the second. sad.gif

hi i am not a frequent poster but i can empathize with feeling like crap about a situation when you worked your tail off. i have had a lot of years of increasing responsibility and education and at this point i function as a ‘house officer’ and at an indendent level within my institution. i have a physician as ‘backup’ but most everything (including intubations and central lines) i am on my own. i can’t tell you how many times i felt people were not kind and then once i got to know them better (as previously posted perhaps ‘win them’) we found a more comfortable spot.

it is terrible for you pilar because it is the written eval thing which makes it difficult to just forget about and move on (at least that’s my impression). however, once you have done what you need to do for follow up you should move on. things like this will drain you. when i first learned airway management it felt like i had an audience at the end of the bed when i was intubating. many times it felt like people were mentally jinxing me. i didn’t pray for a good airway for a patients sake it was so no one would say 'see?? she didn’t get it". as i became more confident and sure the audience seemed smaller and less important. i also lost less sleep about how ‘i felt’ about something or worse how i thought ‘someone felt’ about me. sometimes things do eat at me for a few days but my skin has gotten thicker, but mostly it’s my own oversights i lose sleep over.
i would tell you in retrospect if you had seen any pediatric patients that you felt were in danger or near ‘malpractice’ you should have logged that and reported it appropriately. becoming less attentive or distant is looking the other way. if you are aware of a error it is just as much your responsibility to report it if not already done so.
also, i would say as a previous poster said perhaps she perceived you as questioning her expertise. in this case perhaps it should have been but i guess if i was working with you on that day and you picked up on my oversight (and why dear god if the kid had lead poisoning weren’t the abnormal labs flagged?) i would probably react better to something that didn’t make me feel like you were calling me ‘an expert’ and chiding me a bit. i’m not sure what the correct words were but you get my jist.
and lastly in defense of nurses because despite my path i will always be one to some degree …i found the title of your post a bit uncomfortable. what if she was on a web site and had a posting that said ‘out smarted by a med student !’ it just seems to draw a big line in the sand.
i do hope your next rotation is better. don’t bring this old baggage with you. good luck.

I do apologize for the title and in fact after I had posted the title I realized that it sounded wrong, albeit I just tried to post by whom I had been trashed. I in fact e-mailed the forum to remove the title so I could re-post it. Well, lesson learned I guess. smile.gif

regarding the titile i just thought of it afterwards…it would have been something i would have done and then said afterwards…i wish i didn't do it. clearly though i think it reflects the enormity of emotion that you felt about the situation. as i said i feel bad you had such a tortorous rotation. one person really can make all the difference . good luck to you.