Dealing with a malignant program director

[jl lin]

Hopefully my last comment on this topic but my advice again is to analyze your situation and make the best decision on what you know and feel is the right thing to do.

I described above where a resident had the GME/ACGME involved and it worked. I will not go into details about that situation but just know that there could be another option versus tolerating an injustice. I know many don't want to hear this but discrimination still exists in America.

Does this relate to the OP situation, althogh highly unlikely but something to consider.

The problem is this, and I do believe some are reticent to see it. Bullying of all forms exists. Bullying is considered "OK," particularly if there will unlikely be any kind of EEOC claim or fight attached to it.

Not liking someone's personality or resenting them for intelligence, level of compassion/empathy, personal appearance, any number of things should NOT be enough to fire someone; but the truth is, it definitely happens. It is allowed every, single day, and it has been for centuries. The At-Will-Employment doctrine is an old doctrine, and the weight of any benefit of it goes mostly to the employer. And even though residents have contracts, sadly they only have relatively short-term contracts.

What causes me to feel sadly is that people don't want to address the reality that subjectivity, even with re: to social behaviors and such, can indeed be put in more objective terms and require specifics written under certain guidelines. Capricious, even subtle bullying should not be allowed, but it it. And mostly it is accepted and people look the other way or play into it.

You can always make a false claim about someone and get others on board with the most influentials to oust them. A person can have 90% or better of others with whom they work that know full well that person does indeed work and play well with others. All you need are influentials--people with power, influence, clout--the people no one wants to go against b/c of their influence and power, and so out of fear or affiliation, the others go along with it or stand back and do nothing, and then the person is gone. Again, special "gloves" are used when there is some fear that a target could make an EEOC violation claim. If the person would have a tough time making such a claim, it's not at all difficult to do capricious weed-outs.

In fact, the employer basically holds pretty much all the cards. And that may well be fine to a certain degree; EXCEPT when their are grossly subjective "measures" that are used and abused capriciously to oust good practitioners.

IMHO, the more specialized the unit/area/department, the more likely you will see this sort of thing.

Should the person want to continue in such a toxic environment? Well no, surely they probably would jump to get out if they could. And if it is toxic enough, the should. I get that. Still, he or she needs to continue her/his training, and there is certainly no guarantee these political games are not going to go on elsewhere, or even that a former place will not influence a latter place.

Also, people do actually give subpar references unfairly all the time. Certainly this is not at all true of everyone for God's sake. But it happens enough to be concerning. And for malicious people, it is about being sly. All this business about it being illegal is nice and well and good, but the truth is this: what one person says in a telephone call (mostly likely occurrence) or even in a face-to-face (say at a conference or whatever) meeting with another, will usually never be known to the person seeking the reference.

The only fair and rational way to deal with this is to develop and apply the most objective measuring systems, which allow for specific and clear elaboration.

If not, then the only other solution is to just keep going with capricious systems of evaluation and have residents or whatever group of workers to which we are referring continue to play the abusive kiss-a$$ games and use some form of ingratiating theory in order to survive.

YES! No doubt! People do need to work and play well with others, but they also need to be themselves and should not have to attempt to completely morph into something that they are not--kiss-azzers or purveyors of some ingratiating theory or tolerant of abuse and bullying in order to survive. When this is not done by recruits--person is polite but does not engage in ingratiating themselves to the powerful others, or the person is polite but sets reasonable boundaries on abuse/bullying, they can easily be bullied even more--the game just gets more subversive. So not only is the abuse immoral, but the point of the program--the focus of learning and growing--is shifted to game-playing and abuse and moved off of the essential competencies at hand.

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[Psai]

Where are you at in this process? Are you a resident? An attending? Which specialty are you in?

She's a premed that is looking to apply to medical school in the near future.

 

[jl lin]

/

 

[dozitgetchahi]

I think it's hard sometimes for premeds and med students to see these kinds of threads and not feel fear. You start wondering, wow, could I put in all those years of work and have it amount to nothing because some PD with a personality disorder is out to get me? So I don't fault premeds/students for joining in this thread. They have a vested interest in understanding how the system works. That being said, bashing the system does nothing to help solve the OP's problem. The fact remains that the OP absolutely, positively NEEDS a residency completion certificate if s/he is going to be a physician. The path of least resistance is for OP to finish his/her current program, especially if OP is already a PGY3 in a three year specialty.

And to answer the question for you premeds/med students out there, yeah, there are some residents who get fired. Most are for good cause, although probably a few are more for personality differences. But most residents do make it through, and the odds of you being fired by a nutcase PD for no reason are low.

For premeds and med students whose anxiety is building as they read these threads, I'd just like to say this: MOST RESIDENCY PROGRAMS AREN'T LIKE THIS. MOST RESIDENTS (READ: ALMOST ALL) DO WELL AND THINGS GO FINE.

This is the 'secret' to why pretty much everyone gets through OK (and also the reason why there isn't some massive national backlash among residents). Most PDs are not Machiavellian asshats. At most programs, you will get along well with everyone if you show up on time, work hard, read up, make an effort and get the job done. You're even going to be OK if you make mistakes. (Really.) If I told you about some of the mistakes that were made by my colleagues (and myself!) early on in residency when we were relatively clueless, you'd be surprised at what happened...but nobody brought the hammer down on us. At any decent program, there's going to be an understanding that a certain amount of mistakes are part of the process.

Med students: you can cut your risk of this crap happening to you to almost nil if you work hard and actually match a good program with good leadership. You should try to match solid quality academic programs that are known for treating residents right. Avoiding 'sweatshop' FMG-heavy programs and places with known nasty leadership helps.

 

[Crayola227]

If you think you may be a weaker person, avoid a small program.

 

[22031 Alum]

If you think you may be a weaker person, avoid a small program.

What do you mean?

 

[dozitgetchahi]

If you think you may be a weaker person, avoid a small program.

This too.

It's much easier to 'fade into the background' at a large program where everyone isn't under the microscope constantly.

A lot of this harassment happens at relatively small programs, where it seems every mistake gets overanalyzed and overblown.

 

[jl lin]

This too.

It's much easier to 'fade into the background' at a large program where everyone isn't under the microscope constantly.

A lot of this harassment happens at relatively small programs, where it seems every mistake gets overanalyzed and overblown.

Perhaps, but plenty of people get targeted b/c there is jealousy. Someone starts things and it grows. It will depend upon whether or not the special snowflake will be liked by the influentials. Yea, the work world, especially in healthcare, is a lot like high school in certain respects. Now, even if you are set apart in some negative way by a threatened bully, if you can finesse your way somehow through it and counterbalance the negative with others that will root for you--you can make it to your junior or senior year and be in good shape. Doesn't stop the first two years from being hellish. Even in large programs, if you stand out, even in a good way, and an influential person or persons refuse to accept you, you can still be abused.

Crayola, please define what you mean by "weaker." You can be very strong in a number of ways, and still be targeted, treated, unfairly, and squeezed.
Never underestimate the power of very insecure people with some influence/power. Never.

Point is more objective eval systems can reduce bullying and unfair treatment. If that isn't established, I guess you have to do your best to quietly keep track of your performance on all levels and incidences with some lasting impact. That's easier said than done for the person trying to learn, be safe, and juggle a zillion things at one time, while still trying to keep people happy.


Again, thanks for the topic and thanks for letting me play along.

 

[Perrotfish]

This too.

It's much easier to 'fade into the background' at a large program where everyone isn't under the microscope constantly.

A lot of this harassment happens at relatively small programs, where it seems every mistake gets overanalyzed and overblown.

The tradeoff, though, is that its also easier to fire a resident at a large program. In a 30 resident class ts easy to rearrange oyhet peoples' shifts to hearcover the call from a fired resident. In a 5 resident class when you lose a resident generally there's no way to get that call covered other than to either hire midlevels or force the attendings to take more calls. That's a much bigger deal. Actually when my program's 3rd year class lost two residents (temporarily, to illness). That's exactly what happened: the attendings got to take senior resident night float.

I would need to see statistics showing that small programs fire residents at a higher rate than larger programs. Otherwise I don't thank you should assume one is safer than the other.

 

[22031 Alum]

The tradeoff, though, is that its also easier to fire a resident at a large program. In a 30 resident class ts easy to rearrange oyhet peoples' shifts to hearcover the call from a fired resident. In a 5 resident class when you lose a resident generally there's no way to get that call covered other than to either hire midlevels or force the attendings to take more calls. That's a much bigger deal. Actually when my program's 3rd year class lost two residents (temporarily, to illness). That's exactly what happened: the attendings got to take senior resident night float.

I would need to see statistics showing that small programs fire residents at a higher rate than larger programs. Otherwise I don't thank you should assume one is safer than the other.

That's what I was thinking when I asked for clarification on the statement that smaller programs are better. I'm in a field where programs are smaller in general. But comparing within the field, the bigger programs could theoretically kick someone out with much much less turmoil in the schedule for the remaining residents. If we're working on the assumption that there are programs looking for reasons to get rid of residents (not true for 99.99999% of programs) it'd be easier for the bigger programs.

Since we're going down the road of thought exercises, @jl lin What 100% objective evaluation measure do you propose? How would you stop subjective opinions from sneaking in?

 

[Crayola227]

You guys are right on what you said about firing at small vs larger program.

The only thing that will be universally true is that the microscope is worse at the smaller program, and you're more likely to be branded by your fellow residents (I remember at my alma mater med school which had a sizeable program, midway through someone's 3rd year they commented how they had never worked with another 2nd yr in their whole time there, and while that happens at small programs that's less so, everyone feels like they know everyone even when they don't, the gossip is more diluted at larger programs). 3rd years were coming on who had never worked with a given attending ever. There's obviously a downside to that which is that if you never get to know your attendings it can be very difficult to ever learn to please anyone. On the other hand, if injustice is really going on maybe that's more likely to be recognized by your peers at a smaller program.

Perrotfish also made a good observation about whether or not the program is FMG heavy. Those are the small programs I'm guessing that are more likely to ship you out because they can just pull in another FMG and no one's the wiser. If it's an academic uni all AMG MD program, they can't really pull that off as nicely.

Some other thread pointed out that team structures that are 1 senior 1 intern and 10 patients starting day 1..... are not necessarily the key to success and there is an awesome @Perrotfish post not too long ago on how that is like expecting someone who's never lifted a barbell of any size to start training with one that weighs 100 lbs (misquoted).

What I mean by weak is if you are slow or inefficient, insecure, or mousy. If you have 20 patients and 2 or 3 interns, plus a senior, work can be shifted around for the weaker member to try to catch up. It's a bit less sink or swim that way.

In any case, don't think you're safe at a small program. Don't think you're safe at a large program.

"Rick Grimes: You are not safe. No matter how many people are around, or how clear the area looks, no matter what anyone says, no matter what you think, you are not safe. It only takes one second. One second and it's over. Never let your guard down, ever. I want you to promise me."

TLDR:
smaller programs are able to give you "more personalized attention" take that for what you will
larger programs can shift work around more easily, that could be a good thing for you or a bad one
FMG heavy programs probably find it easier to replace you with an FMG and not hurt their rep
when you remember what a huge The Walking Dead fan I am my viewpoints at least are internally consistent in that lens even if you think I am ridic
weakness as a resident is measured in knowledge base, safety, speed, efficiency, political saavy, ability to keep mouth shut and smile

 

[Crayola227]

Perhaps, but plenty of people get targeted b/c there is jealousy. Someone starts things and it grows. It will depend upon whether or not the special snowflake will be liked by the influentials. Yea, the work world, especially in healthcare, is a lot like high school in certain respects. Now, even if you are set apart in some negative way by a threatened bully, if you can finesse your way somehow through it and counterbalance the negative with others that will root for you--you can make it to your junior or senior year and be in good shape. Doesn't stop the first two years from being hellish. Even in large programs, if you stand out, even in a good way, and an influential person or persons refuse to accept you, you can still be abused.

Crayola, please define what you mean by "weaker." You can be very strong in a number of ways, and still be targeted, treated, unfairly, and squeezed.
Never underestimate the power of very insecure people with some influence/power. Never.

Point is more objective eval systems can reduce bullying and unfair treatment. If that isn't established, I guess you have to do your best to quietly keep track of your performance on all levels and incidences with some lasting impact. That's easier said than done for the person trying to learn, be safe, and juggle a zillion things at one time, while still trying to keep people happy.


Again, thanks for the topic and thanks for letting me play along.

Um, sorry jl lin, I will say that most of the issues of residents being targeted have nothing to do with jealousy. It quite literally made me laugh out loud, the mere idea. Maybe some nurses are jealous of the residents because they don't know any better, but as a rule residents are an object of scorn and pity at least by any other docs anywhere you go.

You are exactly right about the insecurities that abound. You think because you are an intern you can offer medical factoids from uptodate or preface everything you say with "I'm not really sure I think I read somewhere" or "I could be wrong" or some such drivel and be safe but no. Even an attending can get butt-hurt because the intern knew off the top of their head what the most recent guidelines were for starting insulin in DM2 and they didn't.

Looking too smart is frankly more dangerous than too dumb, you are right on that one jl lin. You want the test scores to prove you smart if you seem too dumb from keeping your mouth shut which is the best way to go.

 

[22031 Alum]

Um, sorry jl lin, I will say that most of the issues of residents being targeted have nothing to do with jealousy. It quite literally made me laugh out loud, the mere idea. Maybe some nurses are jealous of the residents because they don't know any better, but as a rule residents are an object of scorn and pity at least by any other docs anywhere you go.

You are exactly right about the insecurities that abound. You think because you are an intern you can offer medical factoids from uptodate or preface everything you say with "I'm not really sure I think I read somewhere" or "I could be wrong" or some such drivel and be safe but no. Even an attending can get butt-hurt because the intern knew off the top of their head what the most recent guidelines were for starting insulin in DM2 and they didn't.

Looking too smart is frankly more dangerous than too dumb, you are right on that one jl lin. You want the test scores to prove you smart if you seem too dumb from keeping your mouth shut which is the best way to go.

Are you done with residency yet?? Because once you have that completion certificate you really should name your specialty and program(s??). Clearly you were subjected to something awful to have made you come to such, frankly, abnormal (compared to the 99.99999% who make it through fine) conclusions about residency. I am concerned that med students or pre-meds who read your posts are getting a wildly inaccurate picture of what residency is like. Attendings getting butt-hurt when their residents know things??!! Not impossible (nothing is) but uncommon. Rare. Not sustainable in a true teaching environment. Maybe in the crappy education-free programs that see residents as service labor and nothing else... but we shouldn't be trotting those places out as an example of residency in general.

 

[dozitgetchahi]

Yeah, I've never experienced this 'persecution for being smart' that seems to have become part of the SDN conventional wisdom. Not in med school, not in residency. Our attendings WANT input from residents and are totally willing to give-and-take in terms of management if you come off as somebody who knows what they're doing.

Looking smart >>>>> looking dumb or being quiet in just about every medical situation I've been in. (As long as you aren't an ass about it.)

Sometimes I wonder if people who run into this problem are just being really pushy and nasty with the attendings.

 

[jl lin]

I am with so much of what you say, but please make note that I didn't say perfect, thus 100% implies perfect. That point probably got lost in my verbosity. LOL

If we can do better, we should do better. Therefore, it's about striving to make the behavior/social metrics as objectively measurable as any other. This, as I have said multiple time, means employing things that are time-consuming. I wrote a paper on it and my professor ardently encouraged me to publish it in a respectable nursing journal.

Of course systems must continue to be developed to meet the needs of resident physicians, but a number of the behavioral/social measures are similar. It's a process though, and processes must continually be tweaked.

It's kind of like how people really have to tweak and honestly evaluate where there may be hidden aspects of racisms or such. We may want to believe we are 100% racism free, but in reality, it's not that simple.
So we have to keep it in check by looking at what the expected performance and prognostic indicators are based on more objective measures.

If there is a variance, that has to written up in such as way as to demonstrate a consistent pattern of falling short of the measures and any extenuating factors, and it must have a clear plan for performance improvement. Subjective terminology has to be tossed aside in the write up.

I know this has been done. I am saying, however, to tweak it, especially with re: to behavioral measures and PIP f/u.

Obviously there is no way to make things perfect. But limiting the capriciousness factor or the BS-pretext factor as much as possible is essential IMO.

We are taught to be understanding and respectful to patients, but what about each other?

I will add, and I will probably get some nurse-whiplash for this, that in general, I feel physicians are more professional with each other in this regard as compared with nurses. I honestly don't understand the dynamics of this, after working many years as a nurse.

And it is certainly not true for all nurses in all places all the time, but truthfully, there can indeed be a lot of bullying behavior. Too often IMHO nurse managers lean too heavily on the antics of certain nurse cronies to do things they should be doing. They defer their leadership and go w/ whatever the cronie-influentials have to say.
Sometimes the NMs are even fearful of pizzing off these influential people to whom they defer. They can't afford to do this if they want to get to the next level while climbing the administrative ladder.

Much of leadership in nursing has changed substantially over the last 20 years. There are almost no NMs that will pull up their sleeves in an urgent situation, much less put a lot of time into striving for fairness, which totally speaks to why there is so much trouble with nurse-morale in many places. Sad.

 

[chocomorsel]

LOL You speak truth.

I take it that your friend didn't win his/her case, or was there some other fall-out?

No she didn't but won the appeal. Whatever that really means. Another trial?

 

[jl lin]

Um, sorry jl lin, I will say that most of the issues of residents being targeted have nothing to do with jealousy. It quite literally made me laugh out loud, the mere idea. Maybe some nurses are jealous of the residents because they don't know any better, but as a rule residents are an object of scorn and pity at least by any other docs anywhere you go.

You are exactly right about the insecurities that abound. You think because you are an intern you can offer medical factoids from uptodate or preface everything you say with "I'm not really sure I think I read somewhere" or "I could be wrong" or some such drivel and be safe but no. Even an attending can get butt-hurt because the intern knew off the top of their head what the most recent guidelines were for starting insulin in DM2 and they didn't.

Looking too smart is frankly more dangerous than too dumb, you are right on that one jl lin. You want the test scores to prove you smart if you seem too dumb from keeping your mouth shut which is the best way to go.

But that is such a shame. I know gunner types are totally annoying. If however the resident is truly interested and has done the research and such, why should this not be a learning moment for everyone? There is something very, IDK, unhealthy in that approach to education. No one would expect every attending to know everything all the time. They are working and may not always be the most up-to-date on everything. Understood. So, again, this is an opportunity for everyone. It doesn't take away from the substantial knowledge and experience that the attending has. To me, this is a tone that has to be re-set for the good of everyone. Yes, I have learned to be pragmatic, but my idealistic/principle-based side does not die off easily.

About the nursing thing. Well, I think that some percentage of nurses, for whatever reasons, feel in the "one-down" position. See I don't feel that way as a nurse. I respect all of our contributions--from the RTs, to the SWs, to Pharmacy, you name it. No one person would be able to do or implement anything without a concerted team effort. I have never felt "less than" as a nurse. I have been happy and proud of how I have contributed as a nurse. I would be fine staying a nurse, but I like to learn and do other things--there are clear limitations. The path of least resistance would indeed be for me to stay a nurse or to even teach again.

But not every nurse was into learning to become a nurse in the first place. Sadly, it was a way to make a decent living w/o the arduous work of say, becoming a physician. There are nurses that are indeed happy and feel quite good about what they do as a nurse. If you have the right brains and attitude and I think personality for it, there can be a ton of joy in being a nurse--also a ton of aggravation, but that goes for any job.

 

[jl lin]

No she didn't but won the appeal. Whatever that really means. Another trial?

I just have a strong hate for injustice. And I really think with regard to students that become medical students that become residents, so MUCH is on the line as compared to other professions/occupations. I mean, that a person can be completely crushed so by an unfair evaluation or accusation--with so much on the line, it's inhumane to me. And that seems ironic in that becoming a physician is supposed to be a humane, care-based profession.

 

[jl lin]

Yeah, I've never experienced this 'persecution for being smart' that seems to have become part of the SDN conventional wisdom. Not in med school, not in residency. Our attendings WANT input from residents and are totally willing to give-and-take in terms of management if you come off as somebody who knows what they're doing.

Looking smart >>>>> looking dumb or being quiet in just about every medical situation I've been in. (As long as you aren't an ass about it.)

Sometimes I wonder if people who run into this problem are just being really pushy and nasty with the attendings.

I have seen the unspoken, imposed silence during MANY rounds. I believe you that there are other places that are NOT like this.

I don't want to say what areas I was/am working, but 99% of my work has been in well-regarded, academic medical centers.

There are some people that you want leading rounds, b/c they are awesome in knowledge and facilitation. There are others where clearly everyone knows they are best to keep their mouths shut--including residents and fellows.

I think it comes down to this: Some people really like teaching and are good at it, while others don't/aren't. Also, it depends on what's on the "docket" for the day.

 

[22031 Alum]

I have seen the unspoken, imposed silence during MANY rounds. I believe you that there are other places that are NOT like this.

I don't want to say what areas I was/am working, but 99% of my work has been in well-regarded, academic medical centers.

There are some people that you want leading rounds, b/c they are awesome in knowledge and facilitation. There are others where clearly everyone knows they are best to keep their mouths shut--including residents and fellows.

I think it comes down to this: Some people really like teaching and are good at it, while others don't/aren't. Also, it depends on what's on the "docket" for the day.

Bolded for emphasis. Just watching, you can't really know the silence wasn't because everyone agreed (or the attending decided) to just power through rounds before going to conference. Or because all the residents know it's best not to give that attending fodder to go off on a tangent, lest you spend an hour on each patient. Or because they did longer teaching "table" rounds before walk rounds, after walk rounds, or at a different designated time. From my experience rounding in the ICU (and in general) all of the above has been applicable at different times and someone watching rounds -even other participants like the nurses or pharmacists- wouldn't necessarily know when all the teaching was happening. It doesn't have to be the "intellectual dictator" scenario you're implying-- though at times it certainly could be. And some people just aren't good at bedside teaching.

Yeah, I've never experienced this 'persecution for being smart' that seems to have become part of the SDN conventional wisdom. Not in med school, not in residency. Our attendings WANT input from residents and are totally willing to give-and-take in terms of management if you come off as somebody who knows what they're doing.

Looking smart >>>>> looking dumb or being quiet in just about every medical situation I've been in. (As long as you aren't an ass about it.)

Sometimes I wonder if people who run into this problem are just being really pushy and nasty with the attendings.

I can easily imagine someone interpreting a situation as "The attending was butt hurt that the resident knew something she didn't." When in actuality the situation was "The resident repeatedly fails to note nuance in clinical situations and dogmatically refuses to deviate from what her book says." Or "Social norms are lost on the resident who insists on proving herself right when it's not the proper time or place, affecting patient care." I've seen that far more often than an attending being upset about a resident being knowledgeable.

Of course, a caveat- I was fortunate enough to train at an amazing program where much was expected of me and much was given in return. We had attendings who would purposely say incorrect things and then call us out if we didn't correct them: "So nobody noticed that I said the wrong dose just now?" Attendings who would be pleased if you brought up some evidence they weren't yet familiar with-- which was rare because they were so on top of things. Attendings who would send you congratulatory pages after you were "un-stumpable" at departmental conference.

I'm sure not all programs are exactly like that, but I'd wager that among the programs SDNers tend to aim for and end up at (meaning the general body of reputable programs across all fields), that general attitude or approach is more common than gets portrayed. Reputable programs want their trainees to know their stuff.

Unfortunately some people end up at places where education is not strong and residents have no value other than being workhorses. But I don't think it's right to paint a picture that those programs are the majority, or even close.

 

[Perrotfish]

The issue with residents challenging attending management is that it's not a dichotomy between attendings who respond well to it and attendings who don't. It's a continuum of how much evidendence you need to present in favor of your point for them to react well to it.

95% of attendings I've worked with responded well if I cited statistics from a recent AAP policy statement or Cochrane metastudy, and the other 5% were so malignant no one really cared about them. Single well done studies makes it more like 75% positive response, and very few truely negative responses. Mentioning what other attendings do, or trying to reason through the physiology of a process to support my plan over theirs, rarely if ever changed anyone's mind and got me an outright negative reaction from more than half of my staff. Finally 'I think I read somewhere', or otherwise unsupported statements got bad reactions from pretty much everyone (varying in degree) even though attendings do the same thing all the time.

 

[jl lin]

Bolded for emphasis. Just watching, you can't really know the silence wasn't because everyone agreed (or the attending decided) to just power through rounds before going to conference. Or because all the residents know it's best not to give that attending fodder to go off on a tangent, lest you spend an hour on each patient. Or because they did longer teaching "table" rounds before walk rounds, after walk rounds, or at a different designated time. From my experience rounding in the ICU (and in general) all of the above has been applicable at different times and someone watching rounds -even other participants like the nurses or pharmacists- wouldn't necessarily know when all the teaching was happening. It doesn't have to be the "intellectual dictator" scenario you're implying-- though at times it certainly could be. And some people just aren't good at bedside teaching.




I can easily imagine someone interpreting a situation as "The attending was butt hurt that the resident knew something she didn't." When in actuality the situation was "The resident repeatedly fails to note nuance in clinical situations and dogmatically refuses to deviate from what her book says." Or "Social norms are lost on the resident who insists on proving herself right when it's not the proper time or place, affecting patient care." I've seen that far more often than an attending being upset about a resident being knowledgeable.

Of course, a caveat- I was fortunate enough to train at an amazing program where much was expected of me and much was given in return. We had attendings who would purposely say incorrect things and then call us out if we didn't correct them: "So nobody noticed that I said the wrong dose just now?" Attendings who would be pleased if you brought up some evidence they weren't yet familiar with-- which was rare because they were so on top of things. Attendings who would send you congratulatory pages after you were "un-stumpable" at departmental conference.

I'm sure not all programs are exactly like that, but I'd wager that among the programs SDNers tend to aim for and end up at (meaning the general body of reputable programs across all fields), that general attitude or approach is more common than gets portrayed. Reputable programs want their trainees to know their stuff.

Unfortunately some people end up at places where education is not strong and residents have no value other than being workhorses. But I don't think it's right to paint a picture that those programs are the majority, or even close.

Sure, but about you first point... Well, residents and fellows talk--people talk, especially if they like and trust you. And when you are in a certain place with certain people long enough, well, things become clear.
It's not like I'm some post-pubescent RN that just fell off the turnip cart. Been doing this a very long time.

Even reputable programs have people leading rounds that aren't as good as others.
But it could also be that some people are so very good at teaching and leading rounds that it puts even the others that are good to shame. There is an art and inherent talent to being a great teacher. I honestly believe this.

Another reason could be the need to plow through b/c of everything going on at the time. The crap hits the fan, and what can you do? In busy reputable places, yes. There can be a lot going on as you know. I have been in bays where two babies were coding and the other was getting close at the same time--and well, this gets in the way of the best laid plans. But yea. I was talking about a few people. Most teaching places are very much about the teaching.

 

[jl lin]

Unfortunately some people end up at places where education is not strong and residents have no value other than being workhorses. But I don't think it's right to paint a picture that those programs are the majority, or even close.

Yes, I would like to avoid this. And thanks for the reassurance.

 

[jl lin]

The issue with residents challenging attending management is that it's not a dichotomy between attendings who respond well to it and attendings who don't. It's a continuum of how much evidendence you need to present in favor of your point for them to react well to it.

95% of attendings I've worked with responded well if I cited statistics from a recent AAP policy statement or Cochrane metastudy, and the other 5% were so malignant no one really cared about them. Single well done studies makes it more like 75% positive response, and very few truely negative responses. Mentioning what other attendings do, or trying to reason through the physiology of a process to support my plan over theirs, rarely if ever changed anyone's mind and got me an outright negative reaction from more than half of my staff. Finally 'I think I read somewhere', or otherwise unsupported statements got bad reactions from pretty much everyone (varying in degree) even though attendings do the same thing all the time.

Some situations I have seen have been where it really comes down to the particular bent or belief of the attending. Some are willing to listen and consider and others aren't. Meta-analyses or anything else be damned. To me, that's sad unless there is some emergency or something urgent happening.

Also, it depends on the culture. Region can make a difference I think. I mean it seems that some cultural influences are more uptight than others. Point: There is difference between being uptight about seriously urgent/critical situations and setting the tone to be uptight over everything. I have friends that spent time at MGH, and well, depending upon where they were, they've pretty much testified that there can be a pretty good amount of uptight-ness a lot of the time.

 

[dozitgetchahi]

The issue with residents challenging attending management is that it's not a dichotomy between attendings who respond well to it and attendings who don't. It's a continuum of how much evidendence you need to present in favor of your point for them to react well to it.

95% of attendings I've worked with responded well if I cited statistics from a recent AAP policy statement or Cochrane metastudy, and the other 5% were so malignant no one really cared about them. Single well done studies makes it more like 75% positive response, and very few truely negative responses. Mentioning what other attendings do, or trying to reason through the physiology of a process to support my plan over theirs, rarely if ever changed anyone's mind and got me an outright negative reaction from more than half of my staff. Finally 'I think I read somewhere', or otherwise unsupported statements got bad reactions from pretty much everyone (varying in degree) even though attendings do the same thing all the time.

Maybe I'm at an especially good program for teaching or something, but where I am there usually is no issue with 'residents challenging attending management' because the residents generally get first dibs on a treatment plan. When a pt gets admitted or seen in clinic, the first question usually is 'what do you want to do, Dr Resident?' All eyes are on you and your stock drops quickly if you can't provide reasonable answers. An attending may force YOU to defend YOUR reasoning, but on general services it won't be happening the other way around as much. (This may be a bit different in the ICU or on other specialty services where fellows/attendings are going to have better knowledge, but still.)

Mentioning what other attendings do prompts a discussion about the range of available treatments (and why staff x prefers one treatment over staff y) most of the time.

"I think I read somewhere" might not change management on the scene with our attendings, but if you can locate the literature later and prove yourself you will definitely earn bonus points.

Reasoning through physiology is also generally encouraged by our attendings...if it's clear that you're pointing out something they missed, they'll hand over the reins.

Never mind that even if you cite literature for a given situation etc, there may still be nuanced reasons why it would be better to do something one way rather than another. One of the biggest ways you learn as a resident is by working with staff who sometimes want to do something a certain way, hearing why they want to do it that way, and integrating whatever makes sense from doing it that way into your practice patterns. EBM ain't always the be-all, end-all of everything you do.

 

[Doctor4Life1769]

I'm not sure it would. A resident's only real defense against the subjective and random nature of residency evaluations is that there are a LOT of evaluators, most of whom don't talk to each other very much. You can bury a hater under dozens of good reviews. Doing something like filing a complaint with the ACGME can make a lot of people who otherwise might have written generic or good evaluations see you as a problem child, and once you start getting bad feedback from all of them the PD has 'objective' data to use against you.

If you think you have something really egregious and concrete for the ACGME to act on it might still be worth it, but I would only light the fuse if you're pretty sure you can sink the person who is harassing you. I don't think you want this particular shot going across the bow.

You assume that faculty and PDs don't talk/gossip. There are cliques that exist even amongst attendings. Depends also on how big or small the program is.

 

[Doctor4Life1769]

Jl Lin, sometimes you are too much. And you clearly don't understand the life of a resident.

OP, good luck child. I was in your shoes for two straight years. We got a new PD mid training who was an evil bitch. A rabid dog. She made my life a living hell for two years. I developed a horrible reputation. Followed by severe anxiety and to this day, I still have to explain my probation to
Credentialing committees and still fight the remnants of anxiety.

Look up my posts circa 2010 thru 2012.

Thankkfully, I found a mentor who thought I was awesome and agreed I was being railroaded by the higher ups, saw a shrink and got on meds, fought with the help of the Union against the planned extension of residency and won, and graduated.

Keep your head down, don't be too vocal like I was about the maltreatment and you can persevere.

FYI, last night I had a nightmare about the evil bitch. More than three years later I still dream about her. That's how much she affected my life.

There are residency unions? Why is this not universal? Sounds like you were incredibly lucky.

 

[dozitgetchahi]

The tradeoff, though, is that its also easier to fire a resident at a large program. In a 30 resident class ts easy to rearrange oyhet peoples' shifts to hearcover the call from a fired resident. In a 5 resident class when you lose a resident generally there's no way to get that call covered other than to either hire midlevels or force the attendings to take more calls. That's a much bigger deal. Actually when my program's 3rd year class lost two residents (temporarily, to illness). That's exactly what happened: the attendings got to take senior resident night float.

I would need to see statistics showing that small programs fire residents at a higher rate than larger programs. Otherwise I don't thank you should assume one is safer than the other.

I'd need to see statistics going the other way to believe what you're saying too.

The vast majority of the sob stories we see on this site seem to come from small FMG-heavy 'sweatshop' programs.

 

[Arcan57]

Book smart residents with poor pickup of social cues are going to occasionally run into problems due to a (partially) unearned sense of self-worth due to their knowledge base. There are definitely clear "yes/no" answers to be found in the literature. But the number of topics that have no literature, small poorly done studies, or heavy commercial bias with significant differences only in non-patient oriented outcomes far outweighs the yes/no. I could easily see becoming frustrated with a resident who is underperforming from a patient care standpoint and is trying to compensate by continuously throwing out literature citations during management discussions in an attempt to prove competence. The worst IM intern I ever worked with could quote every cardiology study written in the last 10 yrs but wouldn't remember to replace potassium in a pt with a K of 2.0 and killed a patient by completely botching an elective intubation that he self-initiated without back up. Knowing the literature doesn't excuse you from not knowing the patient. This is a point most of us intuitively understand, but there are people that don't get this. Unfortunately, this concept tends to be ridiculously difficult to impart if they don't already understand it.

 

[Crayola227]

All of this is true.

My posts earlier are really to say that in medicine, the egos are simultaneously inflated and fragile.
And even the old timers aren't going to tell me my general advice of "keep your mouth shut as much as you can" as an intern is too far off the mark. When you get past intern, especially if for whatever reason you find yourself unpopular, again, start enjoying the tangy taste of your own bit tongue.

 

[Doctor4Life1769]

Book smart residents with poor pickup of social cues are going to occasionally run into problems due to a (partially) unearned sense of self-worth due to their knowledge base. There are definitely clear "yes/no" answers to be found in the literature. But the number of topics that have no literature, small poorly done studies, or heavy commercial bias with significant differences only in non-patient oriented outcomes far outweighs the yes/no. I could easily see becoming frustrated with a resident who is underperforming from a patient care standpoint and is trying to compensate by continuously throwing out literature citations during management discussions in an attempt to prove competence. The worst IM intern I ever worked with could quote every cardiology study written in the last 10 yrs but wouldn't remember to replace potassium in a pt with a K of 2.0 and killed a patient by completely botching an elective intubation that he self-initiated without back up. Knowing the literature doesn't excuse you from not knowing the patient. This is a point most of us intuitively understand, but there are people that don't get this. Unfortunately, this concept tends to be ridiculously difficult to impart if they don't already understand it.

How does an intern self-initiate an elective intubation?
Where was upper level resident oversight?
Why didn't the nurses at least hit that person up or even you?
Sounds odd.

K 2.0 should be replaced but it's not urgently life threatening. It's not like the K was 7.0 and nothing was urgently done about it, leading to eventual v-fib and cardiac arrest.

 

[Arcan57]

How does an intern self-initiate an elective intubation?
Where was upper level resident oversight?
Why didn't the nurses at least hit that person up or even you?
Sounds odd.

K 2.0 should be replaced but it's not urgently life threatening. It's not like the K was 7.0 and nothing was urgently done about it, leading to eventual v-fib and cardiac arrest.

VA MICU, on-site interns. No seniors, fellow available by phone. By time other personnel arrived there was irreversible hypoxic brain injury. Generally the nurses kept the interns from killing patients but the weekend crew had some transitioning floor nurses that were used to dealing with seniors.

 

[Doctor4Life1769]

VA MICU, on-site interns. No seniors, fellow available by phone. By time other personnel arrived there was irreversible hypoxic brain injury. Generally the nurses kept the interns from killing patients but the weekend crew had some transitioning floor nurses that were used to dealing with seniors.

Foolish move by that intern, especially on a weekend in the VA.
Always good to load the boat in these situations, regardless of experience level. That's unfortunate.

 

[Crayola227]

Still sounds sketch.

Luckily the rules have changed as I understand it and you now always have to have an attending or fellow in house. Don't think the intern should ever be senior, fellow, or attending-in-house - less especially the weekend in the VA MICU. Those guys are usually sick as **** and weekend is always poorly staffed. I also don't think floor nurses no matter how good can safely supervise interns.

But point taken on residents who think they are so smart cuz the studies this and that but aren't getting the job done.
Safe fast pleasant is my motto. As long as the patient is better than they were at admit and the attending is happy, I could give a **** less about the lit at this point. If it ain't UptoDate or PocketMed or from conference / something I just happened to read / was forced to read / was hanging in resident lounge / Medscape what's new email then it's cookbook medicine and whoever's going to fry my ass first's plan. Sure I'd love to set the bar higher but let's get real, a lot of time there isn't time or the right audience.

I got by by being a yes-woman and every bit of trouble I can remember having had to do with being perceived as disagreeing with someone. The cure? Stop disagreeing. At this point it takes some serious patient morbidity to get me to cross anyone senior to me.

 

[gutonc]

Still sounds sketch.

Luckily the rules have changed as I understand it and you now always have to have an attending or fellow in house.

Define "attending in house". The hospitals where I round that have IM residency programs have 1 or 2 hospitalists and 1 or 2 ED docs in house at night, in addition to the resident team. None of them are directly attached to the house staff (they have their own teaching attendings) but are available (I guess) when the s*** hits the fan.

 

[Crayola227]

Define "attending in house". The hospitals where I round that have IM residency programs have 1 or 2 hospitalists and 1 or 2 ED docs in house at night, in addition to the resident team. None of them are directly attached to the house staff (they have their own teaching attendings) but are available (I guess) when the s*** hits the fan.

Lords I don't know how to define that.

My program always an ICU attending (may or may not be formally part of the teaching service but would be the go-to) asleep in the attending call room or in the attending office on site or sitting in the bays, and you always had a phone number and pager for them. Ditto for the hospitalist service at night.

Meaning, there was always a number, page, or location to get the attention of an actual attending that wasn't very far from the ward let alone the hospital. At our program the non-teaching attendings on the weekend or at night maybe didn't love it or do a lot of teaching but always seemed OK with jumping in when called, like they knew it was part of the drill working at a place with residents.

Of course as a resident your job is to try to as safely as possible never bother such attendings, but they should be there when needed.

I know what you're talking about though gutonc, I've experienced a situation where the attending was to be called at home and would not help. Terrifying. Luckily the in-house ICU attending was there to pick up the slack.

 

[Raryn]

Lords I don't know how to define that.

My program always an ICU attending (may or may not be formally part of the teaching service but would be the go-to) asleep in the attending call room or in the attending office on site or sitting in the bays, and you always had a phone number and pager for them. Ditto for the hospitalist service at night.

Meaning, there was always a number, page, or location to get the attention of an actual attending that wasn't very far from the ward let alone the hospital. At our program the non-teaching attendings on the weekend or at night maybe didn't love it or do a lot of teaching but always seemed OK with jumping in when called, like they knew it was part of the drill working at a place with residents.

Of course as a resident your job is to try to as safely as possible never bother such attendings, but they should be there when needed.

I know what you're talking about though gutonc, I've experienced a situation where the attending was to be called at home and would not help. Terrifying. Luckily the in-house ICU attending was there to pick up the slack.

Program dependent. My program the PGY3 is the seniormost person inhouse overnight in our ICU. At the VA, sometimes it's even a PGY2. We can self-initiate intubations at the main hospital and just do them with RT for backup (and anesthesia available in-house via page if we ask since they're in-house for trauma call). Have to call them in from home at the VA for intubations per policy, but we've had a couple people intubate there without backup just b/c the situation was that urgent. At both hospitals there is a fellow and attending available via phone that are always quite responsive, but rarely called.

 

[Doctor4Life1769]

RT intubates where I am
We just initiate it. ICU RNs also arrive.
Attending avail off-hours via phone/text

 

[Crayola227]

 

[gutonc]

Lords I don't know how to define that.

Perhaps I should have said "define rules" then. Because there is no ACGME, or IM RRC rule that says an ICU attending or fellow must be in-house. Perhaps that's the deal at your program. But it's not a "rule".

 

[Crayola227]

Perhaps I should have said "define rules" then. Because there is no ACGME, or IM RRC rule that says an ICU attending or fellow must be in-house. Perhaps that's the deal at your program. But it's not a "rule".

Luckily the rules have changed as I understand it

We've talked about reading comprehension. My tone clearly implies some factual uncertainty on my part. If this were Spanish language there would be an entire tense for that (subjunctive) but we use it rarely in English.

What are the actual rules for supervision? I THOUGHT HAD THE IMPRESSION I DON'T KNOW WHERE that someone who makes the rules for more than just my program was that you had to have an attending or fellow in house under certain circumstances or just in general.

 

[rokshana]

Luckily the rules have changed as I understand it

We've talked about reading comprehension. My tone clearly implies some factual uncertainty on my part. If this were Spanish language there would be an entire tense for that (subjunctive) but we use it rarely in English.

What are the actual rules for supervision? I THOUGHT HAD THE IMPRESSION I DON'T KNOW WHERE that someone who makes the rules for more than just my program was that you had to have an attending or fellow in house under certain circumstances or just in general.

sooooo.....in other words you THOUGHT there were new rules in places done by who ever, but really you had no clue and just passing something you thought you heard as an actual fact...but don't actually have a primary source or citation for that, right?

 

[Crayola227]

second or third year internal medicine residents or
other appropriate supervisory physicians
(e.g., subspecialty residents or attendings) with
documented experience appropriate to the acuity,
complexity, and severity of patient illness must be
available at all times on site to supervise first
year residents;
(Core)

page 5
https://www.acgme.org/acgmeweb/Portals/0/PFAssets/2013-PR-FAQ-PIF/140_internal_medicine_07012013.pdf


So I guess you guys are right, the intern is never to be left alone on site, but you can leave it at a PGY2 or PGY3.

but when they say documented experience to the acuity, complexity, and severity of patient illness, I would really scratch my head
certainly a newly minted PGY2 in the VA MICU would be a questionable choice if things went south.....

sounds like there's latitude for how closely programs want to watch residents, at least in IM per ACGME
one program I know of boasted how they always had a fellow or attending on site.... but it was because some bad stuff happened and they were increasing supervision (this was told to me by their chief) and I guess I thought that having like just one attending on site somewhere was like standard, stupid me

I'm guessing what happened is at orientation my terrified intern brain just latched onto the sweet mother's milk of being reassured there would always be someone more senior to me on site

wait a minute, why do we not always have an attending on site? I mean, it seems like there are programs where they are choosing to do this and acting like it's a normal thing to do
is this a crazy high level of supervision to have on an gen med inpt ward or the VA MICU on the weekend? I still can't wrap my mind around the logic of medical training

 

[cbrons]

Which is why people need to look at the objective measures and discipline themselves to follow them.

LOL

 

[cbrons]

Again, this is why programs should maintain objective evaluations w/ full clarification specifics at each point. Also, the evaluations should be done IMHO no less than every 2 mo.s. Going into even a quarter is too long to get sound evaluation feedback.

"Objective evaluation" is an oxymoron.

 

[gutonc]

Luckily the rules have changed as I understand it

We've talked about reading comprehension. My tone clearly implies some factual uncertainty on my part. If this were Spanish language there would be an entire tense for that (subjunctive) but we use it rarely in English.

What are the actual rules for supervision? I THOUGHT HAD THE IMPRESSION I DON'T KNOW WHERE that someone who makes the rules for more than just my program was that you had to have an attending or fellow in house under certain circumstances or just in general.

So basically, you're just going to ramble on and then qualify everything you say, factual or fantasy with "as I understand it". Good to know.

 

[rokshana]

So basically, you're just going to ramble on and then qualify everything you say, factual or fantasy with "as I understand it". Good to know.

this surprises you?

 

[gutonc]

this surprises you?

Not at all. But I appreciate that s/he finally copped to it.

 

[Crayola227]

Not at all. But I appreciate that s/he finally copped to it.

there is no "finally" copping to anything, one reason my posts are so long is having to pre-qualify anything I ever say with either a citation or apparently even if I all have to offer is personal experience anecdote or just outright opinion that is a problem with you people

again reading comprehension, if you want to go back to what my original post was it was clearly just offering a reaction to an anecdote by Law2Doc, it was very clearly started with an OPINION statement "sounds sketch" there was ONE sentence which was factually wrong however in said sentence I expressed some doubt, and ALL the rest of the post was very clearly just opinion on supervision not a statement of any rules, and a statement of how things are done at my program.

what's more telling in your guys' reading comprehension is that you not only just latched onto literally one half a sentence you could find most fault in, and while some people just jumped in to correct me others just did their usual, while short, add on that adds nothing

now that I am re-reading your post to say that I was wrong, it still seems that there is an attending in the building, they just might not be attached to the teaching service

maybe it would be more helpful to point out in the case of the story Law2Doc had, which is that no matter what level of resident you are or what is going on, you should orient yourself at the start of your shift to what attending you would both call or try to reach out and physically grab to help you should you really need it, because I'm still not hearing from anyone that there are zero attendings on site, maybe there is depending on site or speciality I wouldn't know, again, that would be a good thing for the resident to know before initiating an elective intubation, and something I would want to be aware of at the start of any shift any where is how to get a hold of an attending before I need one

EDIT: anecdote was not from Law2Doc, too tired now to say who it was it's above in this thread

 

[Raryn]

because I'm still not hearing from anyone that there are zero attendings on site, maybe there is depending on site or speciality I wouldn't know, again, that would be a good thing for the resident to know before initiating an elective intubation, and something I would want to be aware of at the start of any shift any where is how to get a hold of an attending before I need one

At our rather small VA, where we cover the floors (~30-40 patients) and the MICU (which only has 6 beds, but still usually has a couple intubated patients who may or may not be on pressors), the only attending in house in the entire hospital is in the ER. And they aren't allowed to leave the ER by policy. There are no fellows in house. There is no anesthesia in house. There is literally no one above a PGY2-3 in the entire hospital outside of the ER itself between 5pm and 7am. The attendings are available by phone and it's always perfectly clear who to call if necessary.

At our 650+ bed main hospital, with not infrequently >40 patients on the MICU services (and pretty much never has <30), we have a PGY3 and a PGY2 in house to cover the ICU. The only academic IM attending in the hospital is one covering their own non-teaching service and has nothing to do with any of the ICU patients. The fellow and the attending for ICU are available by phone.