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Discussion in 'Clinical Rotations' started by walkabout123, Feb 24, 2018.
You have 100+ firsts assists because of a previous career? Are you an older or more mature looking student? Do they know about your experience?
I think you can attempt to tell them that you apologize if your eagerness to be helpful was misinterpreted as something else and that was not your intention. I think bringing up safety will once again make it look like you know best (even if you do or don't). Regarding the imaging, in my training and medical school (which was very formal) it was definitely not appropriate for medical students to deliver news to patients without a resident or attending present (and we had reviewed it together). I'm not sure if you meant you were showing the patient imaging they'd never seen before or going over points with the patient that the attending had already reviewed with the patient.
I agree the atmosphere sounds tense. I would honestly avoid any kind of detailed explanation because you guys are obviously communicating on different channels. "Apologize" for the miscues and ask them to go over expectations for the rotation and tell them you want to know how to "get the most out of the learning experience".
Then keep a low profile while following their expectations. I would avoid discussing your personal life with these attendings because they seem like the kind to throw it back in your face. "MS3 was not focused on rotation because of personal sophomoric drama at home. Needs to learn how to be professional at work setting and establish appropriate boundsries" blah blah.
I don't know how you can salvage this for a letter of rec. Maybe it's not as catastrophic as you think (since I don't think attendings think about medstudents when they're out of their sight). Or you're really on their radar and you just have to call the time of death on this rotation.
The best thing about MS3: Just know that at some point... this rotation will end.
I’m going to be harsh sounding here. You are absolutely overstepping your bounds. I’m not surprised your attendings view you as aggressive if you’re seriously considering lecturing them on needle safety. Keep your mouth shut, your hands to yourself, and do only what you’re told unless you specifically obtain permission to do something extra like speak to a patient about imaging you likely have no business showing/interpreting. And for god’s sake, stop mentioning that he’s a male surgeon as if it’s some sort of code for “I think he’s a misogynist.” The general rule is, if more than one attending has an issue with you, the problem is not with the field, or with them...it’s you. Ask them how you can fix it, instead of...whatever it is you’re doing now. Personal stress brings out a person’s worst qualities and if you’re suffering through a breakup, whatever aggressive tendencies you may have are likely being multiplied, and it is showing. Take a step back and examine your behavior from their standpoint, and why they would say what they said.
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Dude, you're in a surgical rotation. A common rule is you never do anything without asking for the permission first. Every place is different and you can't expect to have the same autonomy from the prior rotations. If you don't know what your responsibility is, always ask. You obviously stepped out of bounds. Btw, no one really cares that you're going through a tough time over a breakup. Ppl have other plates to worry about. If you don't like surgery attitude, you should think of going into another field of medicine.
I've said things during surgical procedures that were aimed at safety - and it wasn't an issue. It's one thing to say, "I'm concerned about how protected this needle is," and reaching to move a sharp.
It doesn't matter that after the fact you moved it that they said it was fine where it was - you don't know if you had just raised a concern if in that light it would have been handled differently.
In my experience, if you raise concerns without being aggressive about solutions, people are more inclined not to be as bothered and to address them. That's autonomy, which superiors have, and as a trainee, you do not.
I definitely agree that showing patient's results/imaging is inappropriate as a medical student but in the interest of patient and provider safety I think it's important to speak up about a situation you consider dangerous. I'm on my surgery rotation now and we've been encouraged by multiple attendings as well as our program director to feel free to say something if we're worried about a patient/provider safety issue. Now, should this person have brought it up the way he/she did? Probably not, a better way may have been what was discussed by Crayola, but telling them that they should keep their mouth shut doesn't help patients and doesn't contribute to a positive working environment in any way.
Edited to say that showing patient their results for the first time is inappropriate, going over things after they've been discussed and pt is interested in learning more is often a good job for the medical student to take on with the permission of the rest of the team of course.
I'm sorta with you on thinking he reactions are jerk-like, however, and please don't take it wrong, I think there were better ways to phrase things
you're essentially handling dynamite with how fragile people are in medicine, so just get used to the idea you need to communicate as carefully as it you were doing neurosurgery
I feel comfortable saying this, because I was like the worst student ever, and I swear I got through based on charm alone. Honestly, I think paying this level of attention to communication is good in every sphere of medicine, like when I deal with patients.
"I'm sorry that I moved the needle without permission, I understand now that I should never do anything in a surgery without express permission. In the future, if I am concerned about how safe I am respect to a sharp, what is the best way to approach that?"
Notice how this phrasing doesn't seem like you are defending your prior actions, but the other cxchange might seem to? Also that the last statement implies that you need to change your behavior in the future? That is what people want to hear.
Likely he won't have a good answer, or he would have said "not during a bleed," which if there was none, still doesn't really address it, but that's not the point. Some things will never be good enough for anyone, but seeming to never defend your actions, while accepting any blame, and showing that you want to take responsibility for change to be better in the future, is always going to go over better. It just does.
When he made the comment about being kicked out of medical school, I would have said, "I'm sorry, I see how unacceptable my actions were. I'm grateful to have another chance to continue and improve."
Saying "isn't that the same?" - can you see how that might be taken as you trying to argue? I mean, yes, it could be taken as a simple question made to learn, but it seems to assert your own knowledge, maybe in such a way... people are touchy. I would have said. "Oh, I had it wrong. Since I am wrong, can you teach me what the difference is between the uterine ligament and the utero-ligament is?" And yes, I am aware that here you are saying you are wrong, twice. This puts a lot of emphasis on saying that you are a learner and that you see yourself in the place of needing to be taught by the person with more understanding.
If you catch the attending up (and often you will), if they hand wave, just say "thank you." If they say they aren't sure or don't know and say so, say, "Thank you. I'll have to look it up." Taking responsibility and showing you acknowledge that you are the one in the place of learner.
People love it when you say "I'm wrong," over anything that might ever seem to threaten their sense of being right. Asking someone to teach you because you don't know any better, is much more flattering to someone than asking them to tell you why you're wrong and they're right. This is why whatever you say when someone says you are wrong and you want clarification, needs to send *that* message.
Lol, I'm a Libra. I guess you can see the talent for communication, achieving harmony, or as they say sometimes, manipulation.
Ovarian ligament...you buried the lede there. This is OB? Mystery solved
Basically, it's about understanding that whatever you say can be taken wrong. You have to figure out what principles of communication is going to make the other party happy, and then figure out how to phrase things just for the effect you want.
I'll say more later on phrasing to sort of deal with those times when you really need to correct someone that they are wrong and you are right.
I feel some insufferable medical students love to pull this “I can do everything” a resident can do and try to one-up them. I hope they get burned in residency. The closer I am getting to residency, the more I realize how unprepared I am for this jump. Like there’s no magical rotation you do 4th year which separates you from a third year student besides the sub-Is (yet to do). I hope medical students have mercy on me. The sub-I I had on my surgery rotation at times tried advising the interns and it was just painful to watch. Sounds kind of like something OP would do based on their lack of awareness of the imaging situation and playing it off as something they did on other rotations, “male attending” phrasing, and then just being kind a sore loser about it and saying, “fine, I’ll just kiss ass now”.
There is a great line my attendings used to tell me: everything you want to suggest in the OR, your attending has already thought of it, and thought three steps beyond that. I’m sure the attending was aware of the needle and didn’t have time to deal with it while he had a venous bleed. Additionally there are times when the needle is intentionally left in the field, as in when you’re pulling it through drill holes etc.
“Positive working environment” hahaha.... this isn’t a college safe space. The “positive” part of it should be geared toward the patient, not you. I doubt the patient will care about a needle some OCD med student decides to point out. But they will care if their surgeon messes up a step or doesn’t triage appropriately because some student decided a briefly unprotected needle was a big deal and decided to stick their hands into the field.
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Granted OB (it seems that's what we're really talking about) has a reputation for being malignant. However, it is not the med student's place to go over lab/imaging results. That IMO should be done either by an attending or resident/fellow. Maybe others vary in their opinion if you have done this on other rotations, but the best way to handle this is to ask first and not do.
Also stop with this "male attending" nonsense. There seems to be legitimate reasons based on your post that the attending reacted the way they did regardless of your gender.
I will quote an attending who said something to a student who tried to instruct them on the proper way to pack a wound: “there is nothing you can teach me”
While I have no idea how the needle was lying while your attending was suturing I have no doubt that he and the resident were both aware of it and that they believed (even if incorrectly, not your place to say) that what they were doing superseded their attention to protecting the needle. Nor is it for you to say whether or not there was significant bleeding. Also if I found a student discussing results with a patient without express permission or after I’ve already discussed them you would have been politely asked to take the rest of the day off and an email would have been sent off to the dean about the role a student should have on a clinical rotation.
You have made yourself a nuisance on this rotation and while I highly doubt this will impact your match for residency, assuming your application is otherwise stellar this pattern of behavior could torpedo any fellowship aspirations you may have or generally make residency more difficult with both male and female attendings.
I'm really surprised the whole thing about students going over results with patients doesn't come up as a serious no-no drilled into your brains prior to starting any rotation.
My school had us have patient contact as early as the 2nd week of med school, and keeping your mouth shut, and then not going over results with patients, came up more than once before anyone could frak it up.
It was really neat that sometimes we were expressly told to discuss with patients. On FM a doc might say, "In room 5 with Mrs. Smith, can you go over her blood results that they were normal and she doesn't have anemia, until I get there?"
Ideally you get chances to flex that muscle prior to residency.
We were even encouraged to ask if it seemed reasonably within our skillset (typically normal or confirmatory results).
Now I recall the mantra for training, "Better to ask permission than forgiveness."
A lot of training is learning not just your personal limits, but the limits you have within your training role, the expectations that your superiors have of you. Assuming you accurately know what your abilities are, and what is expected and entrusted to you, you need to focus on building trust with your superiors.
Show them that you "get" it. You do this by focusing on whatever your duties are and excelling there. Responsibility is handed to that sort of person.
Too often we encourage students to show initiative and they don't really know how to go about it. Focus on your primary duties and not pissing people off first.
Then the attending who left a dirty needle off the driver under a sponge when I turned to answer the circulator, which stabbed me in the figure when I put my hands back on the lap to get ready to dab the field is a complete dingus, since he obviously thought three steps ahead and knew I would get stuck.
I'm being sarcastic, obviously. Sometimes people are too busy thinking about what's coming next and do unsafe things. But there is a right way to address them and a wrong way. Just grabbing the driver is the wrong way.
Obviously, what I said applies in most cases, but not all cases. Usually people keep very close track of sharps. Unfortunately, I’ve gotten stuck by idiots as well.
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Yeah, it sucked. Patient refused to be tested. Was fun getting tested repeatedly.
Yep, been there. Also been stuck several times with a sharp from a patient who was floridly hep C positive, untreated. Cue six months of anxiety...
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Are...are you ok? I'm sorry that you seem to believe that you don't deserve a positive working environment. If that's the case then that's really sad and I would be bitter too! I'm not sure why you bring up college safe spaces as a comparison to my point that your work environment should be safe and people should feel comfortable saying something if they're concerned. As for me, I'm happy to have had experiences where I've been encouraged to speak up in an appropriate way if I notice anything unsafe. I'm not saying you start screaming in the middle of a surgery at the attending for an unprotected needle, maybe ask the scrub nurse if you have a question first. I'm sure if you took a step back you'd realize how ridiculous it is to claim that all attendings all the time are aware of everything when, in fact, they are fallible human beings (just like everyone else!) who make mistakes. If there's something I can do to make a situation safer for myself or someone else then I'm going to do it, end of story. The funny thing is, this actual situation happened in the OR just two days ago when an attending left a needle unprotected and the intern spoke up about it and the attending thanked them for it. If you're in a good program where there's an understanding that the more eyes looking out for these things the better, then you should feel comfortable doing the same.
Lmao, bitter? Dear, I’m anything but. You seem to have missed my point entirely, but okay. Speaking your concern at an appropriate time is fine. OP did not do it at an appropriate time.
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The OP sounds a bit arrogant BUT:
We shouldn't outright dismiss her focus on the fact that the surgeon was male. I'm assuming the OP is female. The fact is, sexism still exists, especially with older attendings who may not even realize they are being sexist. Many of my female classmates have experienced disparate treatment from attendings who I found to be very amiable with me.
Second, this surgeon was totally out of line. There was no reason to blow up at OP if it went down as she describes. She wasn't really interfering. She didn't say "you should cut here instead" or "make sure you don't forget to ligate that." She was just looking out for safety--which is drilled into our heads over and over. Medical students have so many meetings where we are told safety is EVERYONE's responsibility, ours included. I don't think any surgeon I've worked with would have acted similarly. In fact, I have covered needles myself without repercussions. I just think this guy was kind of a jerk or having a bad day.
I would be inclined to agree with most of this post, but even if you have surgical experience, as a med student the attending will have certain assumptions of how you will behave in a surgery (only touching what you have been told to touch), so touching even an unprotected sharp without express permission, is unacceptable in most cases.
Besides improperly placing or protecting sharps, the next biggest deal is moving them without verbal communication or prior expectation on the part of people around them.
It was possible for the attending to have reached for that sharp at the same time - people reaching for and moving sharps simultaneously without prior verbal communication is a HUGE source of pokes.
The attending was absolutely correct in correcting this student and making it clear that students are not to handle any sharp without express verbal permission 99% of the time.
OK, maybe that's overstated. However, the point of education stands. Carrying over responsibilities and preconceived notions from prior experiences or roles on the healthcare team, when one needs to be acting at their current training level, rather than this helping, is often problematic.
The way medicine is practiced today is a team sport. Even if you've been the quarterback before, when you show up and you're supposed to be the running back, you better act like the running back. The proper functioning of the team relies on each player meeting expectations for how they will act in executing their role.
Also, it's possible that this attending is sexist, however, since people of both genders have popped on to say that this criticism is relevant outside of any gender biases, again, I'm not sure if that prompted his behavior, but it's beside the point, because the point is valid.
I never touched anything in a surgery that I was not instructed to touch. When I had issues about safety, I respectfully spoke up at a time that *seemed* to me to be as non-disrupting as possible. Obviously as student I wasn't always able to gauge that perfectly as I did not always know exactly what was taking place.
This is not just a medical student issue. Frequently when you do procedures as a trainee (even minor ones like placing a central line), there is more than one set of hands. It is essential that every set of hands knows what the next set is going to do. Verbal communication and closed loop communication is essential.
Even if the student wasn't wrong in *how* they did this, the attending needs to be able to trust how the student will act in a surgery. Doing anything without permission undermines that trust.
The attending doesn't know that you know where the line is on touching things with or without permission, which is why you need to err on the side of a certain sort of conduct.
Perhaps the student wasn't wrong this time, but who knows what they do next time? That is why you cannot act without more autonomy than you are given, and even if your specific actions are not incorrect, you will be given the smack down. That is for patient and provider safety.
The 5 rules I lived by as a med student and then intern in surgery:
1. Don’t break the sterile field (this one was challenging when short me had to stand next to the over 6ft surgeon and even with me on a standing stool his elbow was at the exact same height as my head...!)
2. Keep your eyes sharp and your paws out of the way unless you’re told to do something
3. Don’t touch ANYTHING unless you’re told to
4. If you’re given something to hold, don’t let go until you’re told to
5. Laugh politely at all the surgeon’s jokes
Can someone recap the highlights of OP's deleted post?
"I am a MS3 on my third surgical rotation in a surgical specialty I am considering going into. I am going through a tough time, post break up with someone I thought I would share a life with, and second guessing my specialty choice since this rotation started. I might not seem as enthusiastic or chipper day to day in the rotation for these reasons. Two incidents have occurred and I am left befuddled as to what this all implies/what to do.
On a past rotations I was told to be more confident and assertive. I have first assisted in 100+ surgeries. This rotation is one where they don't let students do much and that part of it has been quite challenging for me as I am trying to determine if this is the specialty for me or not. I already took my shelf exam in this specialty and scored well above average on it so I might come off as confident. I know stuff but I also know that I don't know a whole lot about this specialty.
The other day a attending who previously told me I was "too aggressive" in a operation went off on me during closing. There was a large needle, clamped in a hemostat on the field, the tip was up and unprotected. I was eyeing it for 2 minutes while I stood there, and then in an effort to protect the first assistant and the surgeon from getting stuck I stated "I am going to move this needle." The male attending immediately shouted, "you are not going to move anything. you are not given permission to until you are a surgical attending. the needle is protected!" in a very loud rude tone. I was so shocked I didn't say anything and needless (needleless) to say the remainder of the surgery was quite awkward. I tried to not let it bother me. Now I have to work only with this male surgeon for the next 1.5 weeks. And no doubt he will be grading me.
Any tips on this? I am thinking I will just explain why I said that and that I did it in the interest of protecting them. I can ask the attending what he would like me to do in surgery and just sate that I am used to helping out and moving clutter from the field. I could also say I was stuck by someone else in a prior rotation so I am very cautious about sharps and safety.
I get the feeling that this attending just dislikes me but I don't want this to blemish my record if I still decide to pursue this surgical specialty which is looking less and less likely.
Two hours later in clinic I was caught going over some imaging in with a patient. The other attending told me I am walking around with a chip on my shoulder and that there is a hierarchy in medicine and that they have over ** years of experience on me. They asked me if I went over imaging with patients on prior rotations and I told them I did. How could I have known they didn't want me to do that? I said I was sorry, told them I only was doing what I have known since I never asked/never was told what they wanted from me on this rotation. I also told them about the tough times I have been going through. I asked them how I could improve and they said I shouldn't go on the computer in front of patients to look things up and that I need to be more humble. Things were left on a good note with them but I fear a letter of rec is out of the question/I will get a poor evaluation.
Any thoughts on this mess or how to smooth things over with the needle attending are appreciated."
Thx. learning from the mistakes of others via SDN.
I don't have anything to add to the discussion, but your username brings me back to the good old days arguing about unnecessary political topics on a message board originally designed for running.
The runner's world forum?
No that place was a joke.
Then again, so is Letsrun kinda. But I still love it. Occasionally there is even some running discussion.
I was on runner's world for like a day. Never been to letsrun. I haven't been on a run in over a year.