How To Help Struggling Junior Residents

[Floating Head]

A couple of our CA-1s are drowning. Anesthesia isn't like other specialties, where residents of different year groups work in teams together for weeks at a time, so it is hard for me to see exactly why and where they are weak. We share call nights perhaps once a month, so I barely know them.

Meanwhile, a few of our attendings are telling us that a big part of the CA-2 and 3 residents' job is to teach. Back in their day, after walking uphill to the hospital in the snow, it was residents who taught residents while the staff smoked in the lounge.

What do you do for guys who are headed toward probation or worse?

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[Coastie]

Can you define drowning?

What does it take for a CA-1 to get on probation, or even worse, other than the obvious ethical and outright dangerous considerations?

A couple of our CA-1s are drowning. Anesthesia isn't like other specialties, where residents of different year groups work in teams together for weeks at a time, so it is hard for me to see exactly why and where they are weak. We share call nights perhaps once a month, so I barely know them.

Meanwhile, a few of our attendings are telling us that a big part of the CA-2 and 3 residents' job is to teach. Back in their day, after walking uphill to the hospital in the snow, it was residents who taught residents while the staff smoked in the lounge.

What do you do for guys who are headed toward probation or worse?

 

[UTSouthwestern]

This is a situation that is all too familiar. It is a tough situation for the residents in question as some might already feel browbeaten and incapable, while others may not even acknowledge their deficiencies or issues.

As a junior resident, I was lucky to have senior residents that "took me under their wing" and gave me pointers on everything from IV placement to intubation, to critical care and echocardiography. The key is to offer help in a non-threatening, non-demeaning way. Invite them out to dinner or a social activity after work. Give them an opportunity to ask questions. As residents as a whole, you can organize your own miniworkships wherein you can discuss/show each other different techniques for different procedures as well as discuss your thought processes for various cases and techniques.

Be proactive and get them involved. It isn't always possible to teach and mentor in the hospital on regular working days so you have to make time to do so afterwards. It is a legacy that every resident should receive and pass on to maintain the strength and cohesiveness of our specialty.

 

[Floating Head]

Can you define drowning?

What does it take for a CA-1 to get on probation, or even worse, other than the obvious ethical and outright dangerous considerations?

At my program, formal probation comes after you consistently do poorly, as determined by some kind of majority consensus amongst the attendings. It involves the creation of some kind of specific plan for remediation while beginning the paper trail for firing a resident. I think it's kind of vague and flexible by design.

I think our strugglers are mostly having academic problems, not so much clinical skills problems, and certainly not ethical lapses. They've had their fair share of M&M face time, but nothing too shocking. I think it's low test scores, bad monthly mock oral showings, bad answers under pimping fire, that kind of thing.

 

[bubalus]

These are rather basic ideas, but I think it's important to define the problem. Is their knowlege lacking? If so, why? Is it because they don't read? If so, why? Is it because they are spending too much time in the OR and they get home late every night and don't have the time or energy? Is it because they're apathetic? I once had a college professor who would say, "Make sure you're asking the right question." I think your intervention may be more successful if you can get at the root cause rather than just say, "Read more."

 

[Gern Blansten]

A couple of our CA-1s are drowning. Anesthesia isn't like other specialties, where residents of different year groups work in teams together for weeks at a time, so it is hard for me to see exactly why and where they are weak. We share call nights perhaps once a month, so I barely know them.

Meanwhile, a few of our attendings are telling us that a big part of the CA-2 and 3 residents' job is to teach. Back in their day, after walking uphill to the hospital in the snow, it was residents who taught residents while the staff smoked in the lounge.

What do you do for guys who are headed toward probation or worse?

Just the fact that you are asking the question makes me believe that you are a quality person who will be able to find some way to assist. You have been given some good starting points by the other posters. I wish you the best in your noble endeavor. Sometimes just a mentor is all someone needs to get them on the right track.

 

[Planktonmd]

At my program, formal probation comes after you consistently do poorly, as determined by some kind of majority consensus amongst the attendings. It involves the creation of some kind of specific plan for remediation while beginning the paper trail for firing a resident. I think it's kind of vague and flexible by design.

I think our strugglers are mostly having academic problems, not so much clinical skills problems, and certainly not ethical lapses. They've had their fair share of M&M face time, but nothing too shocking. I think it's low test scores, bad monthly mock oral showings, bad answers under pimping fire, that kind of thing.

Well, They need to stop pimping them every day if they want them to gain some confidence.
Why on earth would a CA1 need a "Mock oral" every month?
I am afraid that the problem is in the system and in programs that care more about their overall exam passing rate than about actually creating good confident anesthesiologists.

 

[militarymd]

Have things CHANGED so MUCH in just 15 years??????

What kind of s hi t is this?

MOCK them....humiliate them.....make them cry....until they either get better or QUIT.

We are a specialty being encroached upon by every other...including non-physicians.

We DON'T need anymore short bus riders who need extra help.

 

[coprolalia]

At my program, formal probation comes after you consistently do poorly, as determined by some kind of majority consensus amongst the attendings. It involves the creation of some kind of specific plan for remediation while beginning the paper trail for firing a resident. I think it's kind of vague and flexible by design.

Ain't that the truth. I've seen this happen all too often. There's rarely a concrete and specific set of instances where the action of the resident is demonstrably shown to have affected patient care. What you get instead is often vague, impressionistic compilation of opinion about someone they don't like. One of the former residents in our program got asked to leave after he did exactly what he'd been told to do in a particular situation. It was sickening. This guy could've made it and have been an awesome gasser if he'd not been segregated and labeled as a "weakling" early on in the program. Eveyr class, no matter how awesome, has the "weakest link". This provides an opportunity to teach and demonstrate that the program is actually capable of training someone instead of just allowing the strong residents to figure crap out on their own. Instead, I'm continually reassured on almost a daily basis that few physicians are truly capable of effectively managing other people.

I am afraid that the problem is in the system and in programs that care more about their overall exam passing rate than about actually creating good confident anesthesiologists.

I think you're partially right, Plank. But, I'm not that optimistic. I think, these days, that what most programs (including mine) really want is someone who can not only easily pass the boards with most self-study, but also someone with whom they can provide minimal supervision. Many programs (including mine) rely almost exclusively on residents getting the work done. It doesn't mean the attendings aren't working either; it means that there are so few qualified and willing academic anesthesiologists out there that there is often a tremendous push to do more with little. Residents become indentured servants, and exists primarily to keep the OR's running. If you are a weakling who can't be trusted for long periods of time by yourself, then you will be isolated and removed from the equation.

Sad.

-copro

 

[Floating Head]

Why on earth would a CA1 need a "Mock oral" every month?

They're pretty nonthreatening and informal. As a CA-1 I usually boned them up pretty thoroughly, but never got picked on because of it. We don't do morning report, so there's no group pimping, and I think if we only did these once or twice a year I'd feel much less prepared for the real thing. I used to hate doing them, but in just the last year I've come to buy into the concept. There's something about being forced to outline a stem and actually say the right words in front of another person that drills things home, at least for me. They've made me a better communicator on regular days too.

Then again, it's easy for me to be philosophical about them because I'm not the one getting beat down.

 

[pgg]

MOCK them....humiliate them.....make them cry....until they either get better or QUIT.

I'm not sure I agree with this, but I will admit that my most abusive and malignant clerkship as a MS3 (gen surg at Walter Reed) was also the one where I learned the most, and grew the most professionally. Fear is a powerful motivator.

We DON'T need anymore short bus riders who need extra help.

Surely there's a happy medium between propping up a hopeless irresponsible apathetic lifestyle loser who'll never amount to anything, and helping someone recognize and overcome their weaknesses. Most people would call the latter "teaching" and agree that senior residents should be doing some of it. But because anesthesia isn't exactly a team sport, opportunities to do so are limited.

It's funny that you use the phrase short bus. The neuroanatomy professor at my med school used to hold extra help review sessions for students who were having trouble. She called them "short bus" classes. I was there, and these days I'm generally regarded as a good resident. Not everyone who needs a push in the right direction is a lost cause or future liability to the field.

 

[Bougie]

I tend to agree with MMD a bit on this one. I don't think medicine is a field for the weak. If you can't cut it I think you should be cut from the team since there will always be 10 people ready to take your spot. It's not like business or law where the worst thing that can happen is you lose the deal or the case; oh well, let's cry about it over a beer at happy hour. I don't want the doc who barely scraped by taking care of me or my family.

The problem is that medical schools pamper and coddle their students, take their money, and send them off to residency ill prepared. These problem residents should have been tossed out 4 years ago.

Sorry for the rant, you touched a nerve there...

 

[pgg]

I don't want the doc who barely scraped by taking care of me or my family.

However high you set the bar for med school admission/graduation or passing the USMLE, there will always be someone who scores the minimum and scrapes by.

There aren't enough of us internet forum doctors with our impeccable credentials, nerves of steel, shart wit, rugged good looks, excellent grammar, trademarked anesthesia techniques, and 98th percentile board scores to take care of everybody's family.

Yes, if someone just can't hack it, or isn't safe, they should be shown the door. But we've all seen exceptional teachers help average people achieve great things. Maybe this thread ought to have more words devoted to that subject, and fewer shots at the allegedly dead weight.

 

[bogatyr]

Have things CHANGED so MUCH in just 15 years??????


MOCK them....humiliate them.....make them cry....until they either get better or QUIT.

.

One of my staff said when he was a resident in our program 15 years ago during morning report they used to make the stupid resident go put his nose in the corner. I guess it's probably hard to quantify how effective such tactics are.

 

[pgg]

One of my staff said when he was a resident in our program 15 years ago during morning report they used to make the stupid resident go put his nose in the corner. I guess it's probably hard to quantify how effective such tactics are.

Heh. I remember rotating through NNMC (the Bethesda Naval hospital) anesthesia department as a med student. During morning report one day they put a pulse ox on a resident and pimped him. He was mocked for his tachycardia after the tougher questions.

Pretty funny, actually.

IIRC, that's where militarymd did his residency, so maybe that explains his position on this matter.

 

[militarymd]

Heh. I remember rotating through NNMC (the Bethesda Naval hospital) anesthesia department as a med student. During morning report one day they put a pulse ox on a resident and pimped him. He was mocked for his tachycardia after the tougher questions.

Pretty funny, actually.

IIRC, that's where militarymd did his residency, so maybe that explains his position on this matter.

Yup....and one of my current partners (co-residents with me at Bethesda) was made to bounce 2 raquet balls while pimped...and made a fool of when he dropped the balls......

If you guys want weaklings and dim witted or FMG's taking care of you or your loved ones...that's fine....I'm not INTO that.

 

[pgg]

Yup....and one of my current partners (co-residents with me at Bethesda) was made to bounce 2 raquet balls while pimped...and made a fool of when he dropped the balls......

If I was subjected to the racquet ball or pulse ox stunts, I don't know if I'd be amused or annoyed, but it wouldn't hurt my feelings.

Regardless, how do stunts like that make residents stronger? Is there any point besides fun at a resident's expense?

If you guys want weaklings and dim witted or FMG's taking care of you or your loved ones...that's fine....I'm not INTO that.

So you're saying a program that doesn't teach residents, offers a sink-or-swim/on-your-own approach to everything, and mocks their weakness produces the best graduates? That's an interesting approach.

I'm all for having high standards ... but systematically abusing everyone in an effort to weed out the bottom 10% (or 50%? 90%? where should the bar be set?) ... that just seems backward, not to mention sadistic.

 

[gas87]

MilitaryMD, I don't think pimp sessions are the ultimate test of being a doctor. Would you rather work with a SOB who can spit out the answers during pimp sessions or someone with a decent knowledge base who busts their a** to help their patients and colleagues?

 

[militarymd]

MilitaryMD, I don't think pimp sessions are the ultimate test of being a doctor. Would you rather work with a SOB who can spit out the answers during pimp sessions or someone with a decent knowledge base who busts their a** to help their patients and colleagues?

where did I say that it was the "ultimate test" of being a doctor?

 

[toughlife]

The ultimate test of of a resident should be a combo of a solid knowledge base and excellent technical skills.

I am sure one can get away with only the latter, but if you don't know why then you will be a 'glorified CRNA" and will fail the boards.

I don't care if you can put an IV in 0.001 seconds if you don't know why you are placing it to begin with.

Having both is what makes you a physician not a technician.

 

[coprolalia]

The ultimate test of of a resident should be a combo of a solid knowledge base and excellent technical skills.

I am sure one can get away with only the latter, but if you don't know why then you will be a 'glorified CRNA" and will fail the boards.

I don't care if you can put an IV in 0.001 seconds if you don't know why you are placing it to begin with.

Having both is what makes you a physician not a technician.

Agreed.

The "why" is equally important to the "how" in being a great consultant. At this point in my training, I've pretty much mastered the "how" but continually work to develop my understanding of the "why" to be a better overall clinician. I don't think this ends with the completion of residency (or, I believe at least it shouldn't).

This is a concept that many of the CRNAs I've encountered can't seem to grasp. They either don't see the distinction and/or don't believe its importance.

-copro

 

[persia]

It sounds like the OP said that the residents were strong enough - but maybe it was more of a general dislike that was being stirred up. Reading the comments, I think our anesthesia dept is pretty decent. The residents are supportive of students and seem to be of each other. The program director is very popular and is well liked throughout the hopsital as an all around decent guy.

That said, surgery (and anesthesia in the or) is pretty dang harsh. I still think that ridicule does more to tear down someone that build them up. Or it creates excellent bs'ers who will lie through their teeth rather than stop and be honest. I liked the idea of helping the residents and being a mentor; sometimes just knowing there is support can make a huge difference. When you know someone is gunning to get you out it can wreak havoc on your confidence and creates a downward spiral.

Another thing - a 'couple of residents' makes it sounds like there is a problem in the program rather than with the residents. Someone is not paying attention to their residents.

 

[Strength&Speed]

eh, nothing

 

[cchoukal]

This is a tough subject because people get such satisfaction out of shame-ing others that it would be difficult to convince them that it doesn't work. From a counseling psycholgist's perspective (my previous life), shame doesn't seem to lead to positive behavior change. Giving fat people a hard time doesn't make them lose weight. Ridiculing your friend who can't stop getting back together with that loser boyfriend doesn't drive her away from him; it drives her away from YOU. And that radiology tech who F-ed up your whole day by losing all your reqs and creating more and more work for you? The one that you want to ream out for their incompetence in front of everyone? My own observations suggest that, although this would be extremely satisfying, it is exactly the opposite thing to do in order to accomplish the actual goal.

On the other hand, the toughies here have a point. No one wants weaklings getting through and taking care of our families. I'm not sure what the answer is, but I think the posters who suggested asking the right question were on the right track.