minor inconsistencies

[saintsfan180]

How often does this happen to you? You get an HPI and someone else goes in and gets a slightly different story. All the time. The patient has more time to think about their answers and the 2nd interviewer gets the opportunity to ask follow up questions that you may not have thought of with the luxury of prior information. Happens when I go in after interns, happens when attendings go in after me. It's part of medicine.

I have this one attending in particular who has been known for being malignant in the past. Well this happened a couple times with him and he went ranting and raving to my PD about how I'm careless and can't be trusted. Doesn't matter that my plan hasn't changed based on any of the details, and that none of them actually matter when it comes to disposition of the patient. When their last cycle was on a chest pain patient that was already getting admitted... how many days a patient had been vomiting, 3 or 4 when they were PO challenged and ready for discharge, if an HIV with fever had an episode of diarrhea or not. Doesn't matter!!

So now every time I see a patient I feel like a whipped dog and I've been so down on myself because I had a complaint to my PD. He wasn't so hard on me and he kind of acted like it was just this person looking for a reason to argue, but still it looks bad on me. I'm doing my best but now I just feel really crappy about my job performance, and I'm second guessing everything I do and everything the patients say to me. I just needed to vent.

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[Birdstrike]

It happens ALL THE TIME. I wouldn't worry about 1 disgruntled attending complaining about some irrelevant s--t (I'm assuming you're a resident). If all the attendings are complaining, that's different.

Pretty soon you'll be out on your own on a single coverage night shift glad you don't have to deal with this guy, while simultaneously wishing you still had this jerk around to bounce ideas off of. (Really, you will).

It happens to everyone, even the best residents. Fact: some attendings are whiny b¡tches. So try not to take it personally. You're not going to change them.

 

[saintsfan180]

Well the thing that annoyed me the most is that he went and told my PD that I sucked basically and he didn't even take it up with me first. He said I was lying to him. Sure we have personality differences, but I'm not going to lie about a patient and put them in jeopardy over something stupid. I just wish he would have said something to me first because I didn't even know there was an issue. As far as I know, I reported what the patient told me and that was it.

 

[EM4life]

I wouldn't stress about it, if you yourself went into the patient's room half an hour later you would likely obtain a different history as well. Vast majority of patients are bad historians, when they have time to think about their answers, they start to change it around what they think is going on or wanna make sure they don't miss anything. As long as you are honest with your attendings and don't make stuff up and say you forgot to ask when you didn't, it will be fine. Almost every program has one of these attendings, personalities don't mesh or there's some sort of ego, there are plenty of amazing academic attendings out there, but there are plenty of dysfunctional weird ones that you will not get along with. Your PD doesn't seem to think it's your problem, so you shouldn't either.

 

[two guys]

You're probably fine. Getting in a perfect groove with every attending is impossible/hard. I wouldn't worry about what was complained about as they seem to be non issues. That being said, its not a bad time of year to compare yourself to your peers and make sure that this complaint isn't part of a bigger set of complaints (ie, you've developed a reputation for lack of attention to detail or laziness and it is manifesting itself as this guy hammering you on non significant aspects of your HPI). I would probably also give some thought to how this guys perception of you compares to your other attendings. If more than half are super excited when you walk in to a shift and give you good feedback without prompting you're probably fine. If most of them are non committal and you only seem to gel with one or two, then you might have some work to do.

I just think that feedback that shows up this time of year MIGHT be based on an 11 or 23 month sample of a bigger problem. I've definitely seen some folks get a reputation and the problems start to show up this way. Seems like the guy doesn't trust you to work under his license. That's either his problem (if its just his personality) or yours. If there is something you can improve on, now is the time.

No need to feel like a whipped dog. This is part of the deal. If I had to go work with all of my attendings from residency again we had some disagreements about management. As long as its just one guy, don't sweat it one bit. Do take the time to give it some honest reflection about your effort. You probably know where you stand. If you think you're solidly average or above average for your peers than move on.

 

[Doctor Bob]

Any attending that doesn't take in to account the phenomenon of historical alternans hasn't been doing this job very long... or lived through residency.
There are ways to tell if the difference in accounts is due to historical alternans or poor history taking on the resident's part though.

 

[CommunityED]

As I was taught in medical school...The only reason the attending's history is never wrong is not because they know more than you (though they do), it's because no one else goes and asks questions after them.

 

[scummie]

This reminds me of a patient I saw as a third year, called the "Case of the Mysterious Rash." Denied everything, explicitly asked about any cleaning products, changes in the home, blah blah, says no. Attending comes in, asks the exact same questions, patient right away goes, "Oh yeah, I got my carpets cleaned last week."

At this point, I assume the majority of my patients lie or at least omit information.

There's a multiplier for quantitative questions too.

"I drink a beer a day." Multiple that by two, you have your real answer. Adjust multiplier by LFTs.

"I only smoke weed." Tox shows weed and coke, other stuff if you're lucky. Multiply x4, divide by BAC level.

"I started smoking when I was 7..." (Pt is is now in his 60s...No need for a multiplier here.)

 

[Groove]

As my esteemed, IM trained, post academic faculty colleague once said to me.. "Being an academic attending was fun, you just have to remember that the resident is always wrong....ALWAYS!"

 

[WilcoWorld]

Doesn't matter that my plan hasn't changed based on any of the details, and that none of them actually matter when it comes to disposition of the patient. When their last cycle was on a chest pain patient that was already getting admitted... how many days a patient had been vomiting, 3 or 4 when they were PO challenged and ready for discharge, if an HIV with fever had an episode of diarrhea or not. Doesn't matter!!

Historical alternans happens on nearly 100% of patients in academic EDs, and an academic attending should really give you a pass on it. However, I find the above part of your post a little concerning. You insist that it "Doesn't matter!!" But diarrhea in febrile HIV can certainly be important. If I were your attending, and I informed you of that bit of history that you missed you could respond in the following ways:
1- "He has diarrhea? Arrg, why didn't he tell me that?!?"
2- "He has diarrhea? Doesn't matter!!"

If you gave response #1 I'd shrug, say that it happens to the best of us and move on.
If you gave response #2 I'd say that you need to read about HIV, take more careful histories, and, if it was a pattern, I'd bring it up with the PD (but only after I discussed it with you).

 

[saintsfan180]

Oh my bad, let me rephrase. Does matter, but not for the disposition from the ER. He's getting admitted anyway and will need stool studies, but it's not something we order out of our ED typically. I'm trying to take this as a point on me though, because I probably could be more thorough regardless of his opinion. So I'll look at this as a teaching point I guess and try to re-iterate with the patient what they have said already when I get ready to leave the room.

 

[WilcoWorld]

Oh my bad, let me rephrase. Does matter, but not for the disposition from the ER. He's getting admitted anyway and will need stool studies, but it's not something we order out of our ED typically. I'm trying to take this as a point on me though, because I probably could be more thorough regardless of his opinion. So I'll look at this as a teaching point I guess and try to re-iterate with the patient what they have said already when I get ready to leave the room.

I think that is a healthy response. If your attending is catching a significant missed detail on 1 in 10 cases, you probably need to take better histories. If the attending is catching an insignificant detail on 1 in than your attending should keep his mouth shut. If your attending is catching an important detail on 1 in 50 patients, well that's what attendings and residency are for!