Getting timely and specific feedback (take two)

[lockian]

So today, I was told my differentials are too broad and include too many zebras, which is not what they'd expect at this time in the year. On prior rotations, I worked with really obvious patients and was told to do differentials "just for practice." Oh yeah, and I kind of thought knowing the zebras might impress someone, but I guess I was wrong. Question: what's the right approach to "zebras"?

I also still don't know how to not have a checklist of questions to ask in my head instead of just "having an organic conversation with the patient." How do I get past this? I've been burned earlier for missing key information, so I hold on to my question lists like a flotation device. I've only ever been able to let go in psych, but with more mediciney things, I am having trouble.

Finally, I'm sick and tired of contradictory feedback such as this, as well as feedback that blindsides me and comes too late. I thought I did well on Peds, and then one of the doctors I worked with (the same one who made the above comments) called me in and told me all this. Now I know I will get a subpar eval, a Pass at best. Interestingly, when I worked with her in clinic (3 weeks ago), she seemed quite happy with me, told me I had solid clinical knowledge, and I at least thought we were able to have intelligent discussions about the patients. Yes, I did ask her what I could be doing differently or better, and she mentioned NONE to the above.

How do I effectively ask for specific and timely feedback that I can actually implement on the same service and/or rotation?

Residents have told me that doing well on rotations is a matter of "acting like you care" but clearly this isn't the whole story.

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[JJMrK]

So today, I was told my differentials are too broad and include too many zebras, which is not what they'd expect at this time in the year. On prior rotations, I worked with really obvious patients and was told to do differentials "just for practice." Oh yeah, and I kind of thought knowing the zebras might impress someone, but I guess I was wrong. Question: what's the right approach to "zebras"?

I also still don't know how to not have a checklist of questions to ask in my head instead of just "having an organic conversation with the patient." How do I get past this? I've been burned earlier for missing key information, so I hold on to my question lists like a flotation device. I've only ever been able to let go in psych, but with more mediciney things, I am having trouble.

Finally, I'm sick and tired of contradictory feedback such as this, as well as feedback that blindsides me and comes too late. I thought I did well on Peds, and then one of the doctors I worked with (the same one who made the above comments) called me in and told me all this. Now I know I will get a subpar eval, a Pass at best. Interestingly, when I worked with her in clinic (3 weeks ago), she seemed quite happy with me, told me I had solid clinical knowledge, and I at least thought we were able to have intelligent discussions about the patients. Yes, I did ask her what I could be doing differently or better, and she mentioned NONE to the above.

How do I effectively ask for specific and timely feedback that I can actually implement on the same service and/or rotation?

Residents have told me that doing well on rotations is a matter of "acting like you care" but clearly this isn't the whole story.

IMO the best way to improve and grow as a medical student (or really, in any environment) is to pay attention and observe the things going on around you. Watch what the residents do, see how the attending reacts, and try to incorporate the things that go over well into your own routine. Feedback is fine, but from what I've seen many of the students who specifically make a point about asking for feedback all the time are not paying attention as well as they probably should. "Feedback" does not only mean a formalized time when someone specifically goes over the things you can improve on. If someone corrects you during a presentation, or states something you said in a different way, or says "here, let me show you" when you are struggling with some task, they are giving you feedback. Honestly, this is probably actually the most real and valid feedback you are going to get. If you come to me at the end of a long day and ask about what you can be doing better, I'm not going to remember all the small things I tried to teach you during the day. But those were the feedback moments.

Get used to contradictions. Every single attending will want something slightly different. There is no one single correct or proper way to perform a task. This can be frustrating as a student because you are used to operating based on whatever rigid structure you have learned for organizational purposes. It's normal. But as you advance and get better, you'll realize that what this actually means is that you can develop your own style, and it won't be the wrong way of doing things (again, because there is not a single correct way).

The stuff you are dealing with is pretty normal. I remember people having similar complaints third year. You'll grow past it, just work hard, learn as much as you can, and trust the system.

 

[FutureInternist]

I always asked for a mid-rotation "what should I do differently" talk
This shows initiative, ability to take criticism & allows them to see that you are taking their feedback to heart (if you do change the things they ask you to)

 

[lockian]

I always asked for a mid-rotation "what should I do differently" talk
This shows initiative, ability to take criticism & allows them to see that you are taking their feedback to heart (if you do change the things they ask you to)

Yeah, but the thing is, we switch services where I am really often. Like every 2 weeks. And there is usually only one feedback form overall.

 

[lockian]

If someone corrects you during a presentation, or states something you said in a different way, or says "here, let me show you" when you are struggling with some task, they are giving you feedback.

Yep, and I tend to be good about incorporating those instant-feedback type of things. I've been told I respond very well to teaching on the fly. I guess I'm just miffed today because in none of my interactions with this particular doc did I ever get the hint that my differentials were not what she was looking for. Maybe I really do need to observe better. I really would like to know how I can avoid something like this in the future.

 

[giantswing]

Yeah, but the thing is, we switch services where I am really often. Like every 2 weeks. And there is usually only one feedback form overall.

Ok, so ask for feedback after one week. And then again at the end.

A lot of residents like to teach, but it is frusterating to spend time teaching if the student seems not to learn. I'd leave the zebras out of it, or at least put them at the end. Too many zebras makes you look obnoxious, while not enough horses makes you look stupid.

 

[FutureInternist]

Yeah, but the thing is, we switch services where I am really often. Like every 2 weeks. And there is usually only one feedback form overall.

That's weird.. you barely have time to get to know the attending's preferences etc

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[evilbooyaa]

It really just depends on the attending. Some like for you to get to what you think it most likely is and go with the plan. Usually in a 1 to 1 setting, this is what happens.

In a big circle jerk setting is when the discussion about a wide differential happens.

My differential on a non-complex patient is 1, maybe 2 explanations for 1 disease process. Sometimes when we sit down and discuss patients on IM we'd go through like 5 or 10, but I never incorporated that into my daily presentations.

Also, I'm not sure if you're doing this, but support your assessment and plan with the history, physical, imaging, etc. Pertinent positives and (the most annoying to mention) pertinent negatives.

 

[lockian]

That's weird.. you barely have time to get to know the attending's preferences etc

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Not only that, but a lot of the time the residents get a new attending every week.

It actually works out that we have the same chief residents for 2-3 weeks, with half the interns/junior residents switching out halfway through, and a new attending each week. And it's anyone guess which of these people will actually evaluate us.

For example, now I am having awful thoughts about an intern having yelled at me. Details notwithstanding, we did turn it into a productive discussion and had a good day working together the following day, but even so -- after that incident I felt like I couldn't do anything right all week. I always wonder -- will the hiccups I have and mistakes I seem to make no matter how hard I try reflect on my evals or not? I do work quickly to correct my mistakes and incorporate whatever advice I get, but what if it's not fast enough, or what if I shouldn't be making those mistakes in the first place? It's a challenge if you really only do get a week to work with somebody.

What if this intern is going to evaluate me -- am I sunk?

 

[lockian]

It really just depends on the attending. Some like for you to get to what you think it most likely is and go with the plan. Usually in a 1 to 1 setting, this is what happens.

In a big circle jerk setting is when the discussion about a wide differential happens.

My differential on a non-complex patient is 1, maybe 2 explanations for 1 disease process. Sometimes when we sit down and discuss patients on IM we'd go through like 5 or 10, but I never incorporated that into my daily presentations.

Also, I'm not sure if you're doing this, but support your assessment and plan with the history, physical, imaging, etc. Pertinent positives and (the most annoying to mention) pertinent negatives.

Yeah, haha, getting all the parts of history, labs, exam, imaging, etc, positives and negatives. I seem to have down now. The issue was that when I was taught to do a differential back in 2nd year, it always felt really artificial to me -- i.e. most of the time I was like, "it's obviously this, what's the point of this exercise?" But I wanted to look like I did the work, so I sat around in clinic thinking of differentials for some kid's otitis media, and now I really do just feel dumb.

But yeah, I legit didn't know that in a 1 on 1 setting a big differential is not what is needed, and would it have really killed the attending to be like -- next time, just give me 1 or 2 ideas.

 

[Armadillos]

what sort of "zebra" diagnoses are people giving you trouble about?

 

[mercaptovizadeh]

The habit of developing broad differentials is instituted so that you can be a physician who thinks through pathophysiology and presentation rather than a midlevel who goes with pattern recognition for a few common diagnoses. As a physician, sure, you're expected to do that same at first as the PA or NP. They learned what they learned largely through experience. As will you, in residency. But you need to have the knowledge base and the diagnostic skill to go to the zebras when your first and second pass diagnoses have failed. When you see a woman who has developed pneumothorax multiple times over the past few years and every time around her period, you'll be glad you read about catamenial pneumothorax and can refer her to gynecology for treatment of her endometriosis after you've fixed her collapsed lung.

 

[lockian]

what sort of "zebra" diagnoses are people giving you trouble about?

You know, it's a funny thing, it's hard to say because this is feedback I'm getting 3 weeks too late so specific situations weren't even part of the conversation. Part of this could in fact be that Peds is a huge subject: internal medicine with some kid-specific particulars thrown in, and I hadn't had internal medicine before -- just psych and neuro. So I kept getting unlucky when it came to reading about the right stuff at the right time.

So I made some stupid mistakes such as bringing up "endometrial cancer" before I ever brought up "thyroid disease" when a girl presented with heavy periods (coag workup was negative). Obviously, I will remember this one forever and never make this mistake again.

And then there was an early elementary school girl with a breast mass. I was asked to do a hypothetical differential before I ever saw the kid. So I said precocious puberty, malignancy of some kind, and, remembering the Pathoma lecture, an injury that went unnoticed at the time and ended up calcifying. I also think I might've said accessory nipple because it wasn't clear from the previsit info where the breast mass was. And I MAY have said my differential in a different order... I don't even know anymore.

But I have no idea if these specific instances are what they were referring to. Like I said, the feedback session did not bring up any specific cases.

I mean, my biggest problem is that I do in fact have a lot of knowledge and am a good reader -- I am told this repeatedly; I'm even the student who's often commended for being proactive about reading about patient conditions and sharing what I find with the team. But when it comes to making decisions on the spot, everything gets jumbled in my head and I make ridiculous mistakes that I should not be making (i.e. the thyroid vs. endometrial cancer in a teenager fiasco).

Part of me wonders if I should be evaluated for an anxiety or learning disorder...

 

[hmockingbird]

So I made some stupid mistakes such as bringing up "endometrial cancer" before I ever brought up "thyroid disease" when a girl presented with heavy periods (coag workup was negative). Obviously, I will remember this one forever and never make this mistake again.

And then there was an early elementary school girl with a breast mass. I was asked to do a hypothetical differential before I ever saw the kid. So I said precocious puberty, malignancy of some kind, and, remembering the Pathoma lecture, an injury that went unnoticed at the time and ended up calcifying. I also think I might've said accessory nipple because it wasn't clear from the previsit info where the breast mass was. And I MAY have said my differential in a different order... I don't even know anymore.

But I have no idea if these specific instances are what they were referring to. Like I said, the feedback session did not bring up any specific cases.

I'm also just an MS3 so take this with a grain of salt but when I go through differentials with residents here, they all seem to have a format that they follow every time. Maybe trying that out would help you?

For example, one way a lot of residents do it is starting out with "What is it most likely to be?" and then "What is the worst case scenario?" Then they go into some other reasonable alternatives. I like this because it tells them you KNOW which one is most likely, but you're also considering the possibly-zebra worst case scenario.

A lot of them also go through their differential in order from most likely to least likely and explain why for each one (pertinent positives and negatives).

Obviously a lot of this depends on the attending's style too and what they want to hear, but I've found trying to copy their approach to be helpful.

 

[lockian]

I'm also just an MS3 so take this with a grain of salt but when I go through differentials with residents here, they all seem to have a format that they follow every time. Maybe trying that out would help you?

For example, one way a lot of residents do it is starting out with "What is it most likely to be?" and then "What is the worst case scenario?" Then they go into some other reasonable alternatives. I like this because it tells them you KNOW which one is most likely, but you're also considering the possibly-zebra worst case scenario.

A lot of them also go through their differential in order from most likely to least likely and explain why for each one (pertinent positives and negatives).

Obviously a lot of this depends on the attending's style too and what they want to hear, but I've found trying to copy their approach to be helpful.

True, I guess. I will try that. For my part, when I am asked to do a differential I am frequently trapped one on one with an attending in clinic. I haven't gotten a chance to observe a lot of residents do differentials because in settings where residents are to be found, the majority of patients we work with already have a diagnosis by the time they get to us.

I've decided I will straight-up ask people how they like their differentials done. Maybe even say up-front that this is something I want to spend some time on improving, because of this-and-that feedback I have gotten in the past.

 

[mercaptovizadeh]

You know, it's a funny thing, it's hard to say because this is feedback I'm getting 3 weeks too late so specific situations weren't even part of the conversation. Part of this could in fact be that Peds is a huge subject: internal medicine with some kid-specific particulars thrown in, and I hadn't had internal medicine before -- just psych and neuro. So I kept getting unlucky when it came to reading about the right stuff at the right time.

So I made some stupid mistakes such as bringing up "endometrial cancer" before I ever brought up "thyroid disease" when a girl presented with heavy periods (coag workup was negative). Obviously, I will remember this one forever and never make this mistake again.

And then there was an early elementary school girl with a breast mass. I was asked to do a hypothetical differential before I ever saw the kid. So I said precocious puberty, malignancy of some kind, and, remembering the Pathoma lecture, an injury that went unnoticed at the time and ended up calcifying. I also think I might've said accessory nipple because it wasn't clear from the previsit info where the breast mass was. And I MAY have said my differential in a different order... I don't even know anymore.

But I have no idea if these specific instances are what they were referring to. Like I said, the feedback session did not bring up any specific cases.

I mean, my biggest problem is that I do in fact have a lot of knowledge and am a good reader -- I am told this repeatedly; I'm even the student who's often commended for being proactive about reading about patient conditions and sharing what I find with the team. But when it comes to making decisions on the spot, everything gets jumbled in my head and I make ridiculous mistakes that I should not be making (i.e. the thyroid vs. endometrial cancer in a teenager fiasco).

Part of me wonders if I should be evaluated for an anxiety or learning disorder...

It sounds like one of your weak points is epidemiology. The bleeding was ******ed because it was a young girl. In an elderly post-menopausal woman, it would be an essential part of the differential.

Don't get too hard on yourself. Just make an effort to learn the mainstream diagnoses and what age/race/sex is affected by them.

 

[Daiphon]

I'm also just an MS3 so take this with a grain of salt but when I go through differentials with residents here, they all seem to have a format that they follow every time. Maybe trying that out would help you?

For example, one way a lot of residents do it is starting out with "What is it most likely to be?" and then "What is the worst case scenario?" Then they go into some other reasonable alternatives. I like this because it tells them you KNOW which one is most likely, but you're also considering the possibly-zebra worst case scenario.

A lot of them also go through their differential in order from most likely to least likely and explain why for each one (pertinent positives and negatives).

Obviously a lot of this depends on the attending's style too and what they want to hear, but I've found trying to copy their approach to be helpful.

Second this.

Just a lowly EP, but the parallel process method - what's probably going on and what's gonna kill the patient - is a good way to look at things. Being able to eliminate things clinically is key; and having an idea of how to exclude other things (labs/imaging/etc) will help you go far.

Cheers!
-d

 

[evilbooyaa]

Oh yeah, things that are most common go first in your differential (assuming the patient is clinically stable and there aren't life-threatening conditions that are reasonable and can be ruled out quickly). Less common things go after.

If there is a serious question of a PE (more than just CP, but including tachypnea/fever/tachycardia/pleuritic-style pain/risk factors, etc.) then that goes first on your DDx (more relevant when you're admitting people from the ED)