Away Rotation (4th year externship)

[psych2b]

Ok, so I thought I'd share a little bit of my recent experience as a 4th year extern (inpatient acute), and see if any of you had comments...

First, let it be known, that I seriously wanted to attend this program, and continued to believe I would like to attend after the following events occurred due to other aspects of the program and my belief that I was completely at fault in all of the scenarios... But, since talking to some other folks, I am starting to question whether perhaps I was not quite all in the wrong...

here we go:

1. Week 1 - I follow a PGY-1 intern to check-in with one of her "regular" patients, and she is doing her daily "How are you" spiel, along with wrapping things up b/c this patient is to be d/c'ed the next day. I ask a follow-up question to one of her statements (making sure she has someone coming to pick her up on d/c).
- Upon leaving the interview room, the PGY-1 intern gently explains to me that I am not to interrupt her during her interview (not as in, interrupt in the middle of her speaking, but as in do not speak at all until she gives me permission, at the end).
- I am a little surprised and aghast that I have committed a faux pas, apologize profusely and then try very hard to not speak during any of her interviews until she turns to me and says "Do you have any further questions?"

2. Week 2 - PGY-1 intern and I go do a first interview with one of her patients, who promptly says "Show me your teeth." The intern replies (a great response): "Why do you want me to show you my teeth?" And the patient gets up and leaves. We return to give a report to the PGY-4 in charge of our team. But, the intern only says "We didn't get anything." So, I was trying to be helpful, and started explaining about the teeth exchange... And we HAD read all of his history (previoius diagnoses and meds), so I thought maybe the PGY-4 would like to know about that, so the intern and I sort of tag-team tell the background. In the midst of this, the PGY-4 pulls out a post-it note, and starts writing on it. I thought she was trying to organize what we were saying, and that if I saw what she was writing, I could tailor what I said (both this time and in the future). So, I stand up to look at it. On it, she has written "Stop Talking!" with 4 arrows all pointing at me. This post-it note was meant for the intern to see, not me. I was stunned and surprised and sad, but I got the message and stopped talking. Later on, when word gets back to her that I mentionned this during an interview as a "weakness" - she apologizes for "having acted out," but is "surprised" that I didn't learn how to "behave" in medical school - and that "while there's no hierarchy per se, medical students do not speak to PGY-4 or attendings, only to the PGY-1 intern, and only when given permission. Medical students do NOT interrupt anyone. We realize that you are trying to impress us, but it shows a real lack of respect." I was surprised because I really hadn't been trying to impress them during these exchanges - I really was just trying to be helpful, not "steal the light" or anything from the intern. I thought we were cooperating. I guess I read that whole situation wrong. Anyway, I make a point of never speaking or asking questions to the PGY-4 unless given express permission.

3. week 3 - we change teams, and I get a new PGY-1 intern. We go in to interview one of MY new patients. To me, this is a new scenario (different than either of the previous ones). Anyway, I interview the patient, and at the end, the new PGY-1 intern asks some follow-up questions regarding the patient's exact history of alcohol use. Because this is my patient, I do not think the old "rules" apply, and ask a follow-up question along the lines of "Wait, was that before or after your last arrest for DUI?" to try and clarify the time-line. Afterwards, the intern very gently explains that I am not to interrupt in the future when he is speaking. I realize that it might seem like I am an extremely slow learner, but to me, this was a different situation because I thought it was MY interview and it was okay for me to ask clarifying questions. I did not consider it to be interrupting because no one was speaking. True, however, I had not been given permission to speak after the intern began his questionning. He was very nice about explaining it to me, but I was feeling like I was extremely dense for not having somehow figured this out already...

4. later on week 3 - we are before the judge, explaining why one of our patients should be held in-patient against his will. The patient advocate explains that the patient has a plan to go live in the woods with the racoons. (This is true). I think that it is relevant and funny to add "Well, yeah, but his plans for food is to 'eat the racoons.'" The advocate and judge both laugh, but the PGY-1 intern does not. Afterwards, I am told that this was inappropriate and that I should not interrupt the patient advocate in the future. Whoops. I understand, but this is now my 4th explanation within 3 weeks about how I interrupt too much. Eep.

So, prior to this externship, I thought I was free to ask questions or make comments, as I seemed appropriate, not when given express permission. I somehow did not realize that silence was expected unless told otherwise - did you guys have that experience as well? Do you really not ask questions during interviews unless given permission? Do you really not try and help give
additional information during the presentation? I feel stupid for not having known this beforehand. And I really was only trying to be helpful, not "impressive" despite their interpretation of my behavior. I guess that's kind of selfish of me, or egotistical, to think that I, as a lowly medical student, could be at all helpful to the higher-ups, but I guess I was naive to believe that. Eep.

Comments? Questions?

Is this a West Coast vs. East Coast thing?
(I am from the East Coast; This program was in the West Coast).

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[OldPsychDoc]

Ok, so I thought I'd share a little bit of my recent experience as a 4th year extern (inpatient acute), and see if any of you had comments...
....Comments? Questions?

Is this a West Coast vs. East Coast thing?
(I am from the East Coast; This program was in the West Coast).

In my opinion, based on how you describe these events, this is a d***headed intern thing, apparently reinforced by at least one senior resident. These people are taking themselves WAY too seriously. (But maybe that's just my "Midwest thing".)

 

[Anasazi23]

Those scenarios seem too incredible to be true. Have you been told in the past, or on other occasions, that you talk too much or are intrusive? I'm just trying to get a handle on how this could happen.

I should copy and paste the above paragraphs into the "malignant programs" thread. It's a good example.

I can imagine this happening routinely in surgery or something like that, but not in psych.

 

[psych2b]

Have you been told in the past, or on other occasions, that you talk too much or are intrusive?

Um, no... my evals and feedback has basically been that I am "open, enthusiastic, a real team-player." I consistently received comments in all my rotations reporting that I "will make a good house officer." I have always tried hard to help my team - never leaving early or stepping on toes. Never showing up fellow students (If I know an answer or looked someting up for them, I share it with them when no one else is listening, so they can report it on their own later). I just never realized I needed permisison to speak, and was truly aghast that somehow I was having such a drastically different experience at this program, as compared to my home school - it's nice to hear that you guys don't think I was horribly rude and that perhaps this program was a little out-of-the-norm. I'm not sure if it's an intern thing, or just this senior resident who had shaped the intern's expectations?

Also, I didn't realize that I was not completely at fault until I met another applicant who had done an away externship at the same place, and he had a similarly weird feeling about the place upon leaving - like there were some expectations of us that we didn't somehow know.

By the way, this program prides itself on being "friendly" and "caring" and "nurturing." If the 2 interns and 1 PGY-4 are treating visiting med students this way, is it possible that I could avoid this scenario in going there? (The PGY-4 will be gone...).

 

[Milo]

"Well, yeah, but his plans for food is to 'eat the racoons."

That is hilarious.

Those types of interactions and involvement in patient care would be considered as highly positive in my program <plug for the non-coast West>.

In some relationships you just have to say: it's not me, it's you.

 

[mosche]

I would NOT even give this program a second chanceERIOD! If it was just the PGY-4's expectations, the others (interns) would have called him/her a *!@#$ when he/she wasn't looking. Since they did that crap regularly, I assume that they have very big egos or very little ___s -- well, you get the point.

I'm from the mid-South, and your behavior/comments would have earned you praise! Heck, down here the judge would have made an effort to to recruit you to law school!

 

[Poety]

Unfortunately, I ran into this during a rotation 3rd year and got a bit of heck for it - thank God it was my frist rotation and I learned IMMEDIATELY that I would never try to add anything except to the intern, so they could tell the 4th year, and then they usually would say "oh, also, poety had added that blah blah" and they would give me credit.

Also, I never ask a question to a patient without first saying, would you mind if I >>>go back in<<<< and ask the patient x,y,z or I say do you think it would be important to know x,y,z.

Interns are insecure. They are new, they don't know a whole lot and they are trying to impress their seniors - so I know better than to make them feel worse especially if my asking questions may make them feel like I either a. know more, or b. am pointing out their deficiencies.

You by right did nothting wrong at all - but I think its the politics of medicine perhaps?

 

[Anasazi23]

Um, no... my evals and feedback has basically been that I am "open, enthusiastic, a real team-player." I consistently received comments in all my rotations reporting that I "will make a good house officer." I have always tried hard to help my team - never leaving early or stepping on toes. Never showing up fellow students (If I know an answer or looked someting up for them, I share it with them when no one else is listening, so they can report it on their own later). I just never realized I needed permisison to speak, and was truly aghast that somehow I was having such a drastically different experience at this program, as compared to my home school - it's nice to hear that you guys don't think I was horribly rude and that perhaps this program was a little out-of-the-norm. I'm not sure if it's an intern thing, or just this senior resident who had shaped the intern's expectations?

Also, I didn't realize that I was not completely at fault until I met another applicant who had done an away externship at the same place, and he had a similarly weird feeling about the place upon leaving - like there were some expectations of us that we didn't somehow know.

I thought as much...but had to ask. If you're anything like how your posts convey, you seem like a genuine, likeable person. Sounds like there is at least one malignant senior resident on a power trip. There's no reason to have these dogmatic rules that essentially don't accomplish anything. You learn about psychiatric patients by talking to psychiatric patients. You won't 'break' them if you say the wrong thing. Of course, knowing what to say, what not to say, and effective interview techniques is a trial-and-error process, to impose rules such as those convey something about the program.

By the way, this program prides itself on being "friendly" and "caring" and "nurturing." If the 2 interns and 1 PGY-4 are treating visiting med students this way, is it possible that I could avoid this scenario in going there? (The PGY-4 will be gone...).

Hard to say. It's possible that you've got a power-hungry senior resident that likes to exert his influence this way, and that things would calm down when he leaves. However, the more likely scenario is that this is a culture that the residents have developed, for whatever reason, and is propagated by having the up-and-coming residents behave in a similar manner.

I prefer a more laid-back atmosphere and I encourage my students to ask questions, ask me why I'm making decision that I am making, and certainly encourage them to interview patients often to become comfortable with the process. Then again, that's just me.

 

[Poety]

Thats why everyone loves you Sazi

 

[Thewonderer]

I would personally not consider that program either!!! but can you tell us or at least hint at which program it might be? like one of those in pacific northwest, northern cal or southern cal?

My general impression is that west coast program is a lot more laid back when Northeast programs. So I am surprised that it happens on the west coast and not on the east coast.

BTW, how come I have seen some Sub-I's rolling their eyes when asked to do something for their patients? I thought that sub-I's are there to impress and they should do something (like digging up old medical records) first, then ask why later???

Ok, so I thought I'd share a little bit of my recent experience as a 4th year extern (inpatient acute), and see if any of you had comments...

First, let it be known, that I seriously wanted to attend this program, and continued to believe I would like to attend after the following events occurred due to other aspects of the program and my belief that I was completely at fault in all of the scenarios... But, since talking to some other folks, I am starting to question whether perhaps I was not quite all in the wrong...

here we go:

1. Week 1 - I follow a PGY-1 intern to check-in with one of her "regular" patients, and she is doing her daily "How are you" spiel, along with wrapping things up b/c this patient is to be d/c'ed the next day. I ask a follow-up question to one of her statements (making sure she has someone coming to pick her up on d/c).
- Upon leaving the interview room, the PGY-1 intern gently explains to me that I am not to interrupt her during her interview (not as in, interrupt in the middle of her speaking, but as in do not speak at all until she gives me permission, at the end).
- I am a little surprised and aghast that I have committed a faux pas, apologize profusely and then try very hard to not speak during any of her interviews until she turns to me and says "Do you have any further questions?"

2. Week 2 - PGY-1 intern and I go do a first interview with one of her patients, who promptly says "Show me your teeth." The intern replies (a great response): "Why do you want me to show you my teeth?" And the patient gets up and leaves. We return to give a report to the PGY-4 in charge of our team. But, the intern only says "We didn't get anything." So, I was trying to be helpful, and started explaining about the teeth exchange... And we HAD read all of his history (previoius diagnoses and meds), so I thought maybe the PGY-4 would like to know about that, so the intern and I sort of tag-team tell the background. In the midst of this, the PGY-4 pulls out a post-it note, and starts writing on it. I thought she was trying to organize what we were saying, and that if I saw what she was writing, I could tailor what I said (both this time and in the future). So, I stand up to look at it. On it, she has written "Stop Talking!" with 4 arrows all pointing at me. This post-it note was meant for the intern to see, not me. I was stunned and surprised and sad, but I got the message and stopped talking. Later on, when word gets back to her that I mentionned this during an interview as a "weakness" - she apologizes for "having acted out," but is "surprised" that I didn't learn how to "behave" in medical school - and that "while there's no hierarchy per se, medical students do not speak to PGY-4 or attendings, only to the PGY-1 intern, and only when given permission. Medical students do NOT interrupt anyone. We realize that you are trying to impress us, but it shows a real lack of respect." I was surprised because I really hadn't been trying to impress them during these exchanges - I really was just trying to be helpful, not "steal the light" or anything from the intern. I thought we were cooperating. I guess I read that whole situation wrong. Anyway, I make a point of never speaking or asking questions to the PGY-4 unless given express permission.

3. week 3 - we change teams, and I get a new PGY-1 intern. We go in to interview one of MY new patients. To me, this is a new scenario (different than either of the previous ones). Anyway, I interview the patient, and at the end, the new PGY-1 intern asks some follow-up questions regarding the patient's exact history of alcohol use. Because this is my patient, I do not think the old "rules" apply, and ask a follow-up question along the lines of "Wait, was that before or after your last arrest for DUI?" to try and clarify the time-line. Afterwards, the intern very gently explains that I am not to interrupt in the future when he is speaking. I realize that it might seem like I am an extremely slow learner, but to me, this was a different situation because I thought it was MY interview and it was okay for me to ask clarifying questions. I did not consider it to be interrupting because no one was speaking. True, however, I had not been given permission to speak after the intern began his questionning. He was very nice about explaining it to me, but I was feeling like I was extremely dense for not having somehow figured this out already...

4. later on week 3 - we are before the judge, explaining why one of our patients should be held in-patient against his will. The patient advocate explains that the patient has a plan to go live in the woods with the racoons. (This is true). I think that it is relevant and funny to add "Well, yeah, but his plans for food is to 'eat the racoons.'" The advocate and judge both laugh, but the PGY-1 intern does not. Afterwards, I am told that this was inappropriate and that I should not interrupt the patient advocate in the future. Whoops. I understand, but this is now my 4th explanation within 3 weeks about how I interrupt too much. Eep.

So, prior to this externship, I thought I was free to ask questions or make comments, as I seemed appropriate, not when given express permission. I somehow did not realize that silence was expected unless told otherwise - did you guys have that experience as well? Do you really not ask questions during interviews unless given permission? Do you really not try and help give
additional information during the presentation? I feel stupid for not having known this beforehand. And I really was only trying to be helpful, not "impressive" despite their interpretation of my behavior. I guess that's kind of selfish of me, or egotistical, to think that I, as a lowly medical student, could be at all helpful to the higher-ups, but I guess I was naive to believe that. Eep.

Comments? Questions?

Is this a West Coast vs. East Coast thing?
(I am from the East Coast; This program was in the West Coast).

 

[psych2b]

I would personally not consider that program either!!! but can you tell us or at least hint at which program it might be? like one of those in pacific northwest, northern cal or southern cal?

But but... So aside from Poety, no one else thinks the behavior of these interns was "normal" and "to be expected" at any program?

The program where this occured is a very small community program in Northern California that no one on the East Coast has ever heard of, but that seems well-known on the West Coast... If you really want to know its ID - either PM me, or go see my interview reviews, and you'll be able to deduce which one it is (it's all in one post, in the post-interview review forum).

BTW, how come I have seen some Sub-I's rolling their eyes when asked to do something for their patients? I thought that sub-I's are there to impress and they should do something (like digging up old medical records) first, then ask why later???

Well... I did every little thing like that I could, but I always do that - I consider it "helpful" and I just want to do what I can in any situation to help out the team - be it searching through the dungeons for a med record gone astray or what-have-you. I don't do it to "impress" anyone - b/c I want them to know what I'm like - and that's how I'll be next year, you know? I guess it might result in the same action, but coming from a different place internally - if that makes any sense?

 

[psych2b]

Also, I never ask a question to a patient without first saying, would you mind if I >>>go back in<<<< and ask the patient x,y,z or I say do you think it would be important to know x,y,z.

Hrm, I wish I'd known that was expected - it seems kind of... different from my expectations, having to ask permission to go back and ask a question - but it seems from the variety of responses to my post that this can depend on the institution - do you mind telling us if you are on a particular coast?

Interns are insecure. They are new, they don't know a whole lot and they are trying to impress their seniors - so I know better than to make them feel worse especially if my asking questions may make them feel like I either a. know more, or b. am pointing out their deficiencies.

Oh dear. I never thought about it like that, and really didn't think that my asking questions could be considered a way to make them "feel like I knew more" b/c it seemed to me that by asking questions, I obviously DIDN'T know... And that I'd like to know, but simply didn't? I certainly wasn't "pointing out their deficiencies" - I guess I thought I was just clarifying for my own confused self (and if it helped the intern/team, then yay, but maybe they didn't need unconfusing) but I see that it could be taken a different way. I guess it's really reflective of a different internal structure, in a way - how one interprets the actions of others... um, that was probably basicy psych 101, but I'm still learning. Thanks for offering another perspective, Poety - I guess I never thought anyone "above" me (i.e., interns, etc) could be insecure around me (lowly med student).

 

[psych2b]

If you're anything like how your posts convey, you seem like a genuine, likeable person.

Aww, thanks Anasazi23.

Sounds like there is at least one malignant senior resident on a power trip.

Funny, I sent my description of the four episodes to one of the PGY-3's I enjoyed working with at this program, to see what her take on the whole situation was, and whether she had experienced anything similar or had similar expectations - I was hoping she'd say "What? Really? I've never encountered anything like that!" so that I could love the program and assume it was all just the influence of that one PGY-4... However, the response I got back from this lovely PGY-3 was "I'm sorry you felt so picked on.[snip] sorry that you felt so bad about it that you had to write such a detailed letter with all your concerns. I have nothing to complain about re the program. I love it here. [snip]I really did enjoy working with you - you were competent and I saw improvement in you with time, plus you asked for input and did not appear entitled/standoffish/wanting to show off. "

So... I guess I surmise a) My list came across as slightly OCD and complainy (whoops) b) She encounters/has similar expectations of non-interruption, AND loves the program (perhaps this implies a good-fit for her vs. me?) c) didn't think I was trying to show-off (thank goodness) when I had been trying to be helpful.

Ok, I realize this was perhaps a bit self-indulgent, posting all my thoughts like this... Um, thanks you all for reading it and offering advice/thoughts. I appreciate them.

 

[Poety]

You are cute and sweet psych, I'm sure you will do very well wherever you go! For me, I will say I am at an eastcoast program- and I learned this from two rotations: Peds and OBGYN, but it just happened to transfer VERY WELL into the other rotations too. Also, about the insecurity comment re: interns - I learned this working as a nurse, from having talked with them and now approaching internship - I can see where they really want that contract renewed and don't want any bad evals - its scary stuff for them.

I try to pick up on the politics in a place just to feel it out and see where I'm expected to be so that I dont' step on toes (I was a pool nurse and you learn to do this in less than 2 minutes when you do nothing but transfer services over and over) - this is not because like I said psych, you at any of those points did anything wrong -but its because others reactions to seemingly "helpfulness" can end up hurting us in the end if we don't read people properly.

I found it very hard to keep my mouth shut in med school - and it did not pay off in the end - in the end, it seems that going along with whats expected is the easier, less painful way

I wish you all the luck - take care!

 

[Anasazi23]

Aww, thanks Anasazi23.


Funny, I sent my description of the four episodes to one of the PGY-3's I enjoyed working with at this program, to see what her take on the whole situation was, and whether she had experienced anything similar or had similar expectations - I was hoping she'd say "What? Really? I've never encountered anything like that!" so that I could love the program and assume it was all just the influence of that one PGY-4... However, the response I got back from this lovely PGY-3 was "I'm sorry you felt so picked on.[snip] sorry that you felt so bad about it that you had to write such a detailed letter with all your concerns. I have nothing to complain about re the program. I love it here. [snip]I really did enjoy working with you - you were competent and I saw improvement in you with time, plus you asked for input and did not appear entitled/standoffish/wanting to show off. "

This sounds like some sort of supportive therapy session, and in some ways, appears to be written with a forked tongue. She's apologizing for the fact that your feelings were hurt, yet not necessarily about the behavior of the resident or intern. Likewise, she makes a point of telling you how much she likes it there, as if to say that she recognizes this malignancy, yet a) either looks fills an ego need by talking to 'underlings' this way, or b) doesn't give a damn. Her finishing sentence is filled with negativity, even though it compliments you...ifyou're into this sort of analysis, one could surmise that this indeed (even in a more 'approachable' resident) that negativity is part of the atmosphere at that program. Trust your instincts, young padawan.

 

[Poety]

Aww, thanks Anasazi23.


Funny, I sent my description of the four episodes to one of the PGY-3's I enjoyed working with at this program, to see what her take on the whole situation was, and whether she had experienced anything similar or had similar expectations - I was hoping she'd say "What? Really? I've never encountered anything like that!" so that I could love the program and assume it was all just the influence of that one PGY-4... However, the response I got back from this lovely PGY-3 was [I[B]]"I'm sorry you felt so picked on.[snip] sorry that you felt so bad about it that you had to write such a detailed letter with all your concerns. I have nothing to complain about re the program. I love it here. [snip]I really did enjoy working with you - you were competent and I saw improvement in you with time, plus you asked for input and did not appear entitled/standoffish/wanting to show off.[/I] [/B] "

So... I guess I surmise a) My list came across as slightly OCD and complainy (whoops) b) She encounters/has similar expectations of non-interruption, AND loves the program (perhaps this implies a good-fit for her vs. me?) c) didn't think I was trying to show-off (thank goodness) when I had been trying to be helpful.

Ok, I realize this was perhaps a bit self-indulgent, posting all my thoughts like this... Um, thanks you all for reading it and offering advice/thoughts. I appreciate them.

Does the above sound kind of insulting to anyone else? There's definitely a strange tone going on here.

 

[kcrd]

It sounds very insincere to me, and it sounds as if the writer is implying that the problem is with the student, not with the program ("I love it here.") Well, it is good that the OP did the away rotation, because now she knows to steer clear of that program.