IM, "It's my first day" ever with difficult preceptor

[trs88]

Anyone know how to work with/ learn from a preceptor that will tell you one thing one day and the very next day after you do that one thing, will now tell you that it's totally wrong?

Some background is that this is my first rotation, I got delayed, and it's IM. It's just the preceptor and myself, no 4th years or residents and the preceptor knows it's my first ever rotation.

For example, he will have me take a patient history by myself, this time the pt has nerve pain. I did my history and afterwards presented it to the physician. He gave me critique and I Incorporated it into the history of another nerve patient that I did today. What he asked that I included is a total head to toe neuro exam, test all the cranial nerves and establish which dermatomes are affected. I do all that and write it on my paper. I presented all the pertinent info and after I finish he tells me it was awful and he was totally confused. No advice on how to improve or what exactly I did wrong.

What I think are some of the issues is that there is a language barrier (he's Indian and I'm Caucasian from Texas), a super star student was his previous student who he still compliments (I think he's comparing me to the former student), and I think he has already forgotten that it's literally my first rotation and has too high of standards.

Yesterday, before the harsh critisism, he told me that he doesn't care if I get 1 million things wrong because he just wants me to learn. So I don't really understand his method to madness. Any suggestions or ideas? Thanks

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[Ismet]

Did you ask him what you did wrong or what you can do to improve your presentation? Advocate for yourself instead of blaming the situation. Take it into your own hands. After he tells you "that was awful, I was confused," immediately ask what you can do to improve.

You will discover quickly that each attending will have different expectations and different ways to do things. It's often a good idea when you start working with a new attending to ask how they like their presentations. Some attendings want all the details. Some want just the pertinents. Some want all the details until they can trust that you know what is pertinent and what is not.

He's right, you're still learning, and it's ok to get things wrong. But if you're not getting the feedback you need, ask for it.

 

[trs88]

Did you ask him what you did wrong or what you can do to improve your presentation? Advocate for yourself instead of blaming the situation. Take it into your own hands. After he tells you "that was awful, I was confused," immediately ask what you can do to improve.

Right after he said he was confused, he stood up from his desk and walked away. Just like that. There was no further communication. I followed after him because he left me hanging and he had started seeing patients again. At that point I let it drop because I have no idea how to bring it back up without sounding confrontational.

The advice you gave is spot on and I am proud to say that I did most of what you suggested on Monday. I managed to get him to sit still for 2 minutes and asked what he wanted. He wants everything of everything. Okay, I can do that. But when I did that (today), and got the less than expected feedback it leaves me flustered because I don't know how to go "hey, you left me hanging. I need to learn enough you pass your rotation but you're giving me contradictory expectations."

 

[Redpancreas]

Anyone know how to work with/ learn from a preceptor that will tell you one thing one day and the very next day after you do that one thing, will now tell you that it's totally wrong?

Some background is that this is my first rotation, I got delayed, and it's IM. It's just the preceptor and myself, no 4th years or residents and the preceptor knows it's my first ever rotation.

For example, he will have me take a patient history by myself, this time the pt has nerve pain. I did my history and afterwards presented it to the physician. He gave me critique and I Incorporated it into the history of another nerve patient that I did today. What he asked that I included is a total head to toe neuro exam, test all the cranial nerves and establish which dermatomes are affected. I do all that and write it on my paper. I presented all the pertinent info and after I finish he tells me it was awful and he was totally confused. No advice on how to improve or what exactly I did wrong.

What I think are some of the issues is that there is a language barrier (he's Indian and I'm Caucasian from Texas), a super star student was his previous student who he still compliments (I think he's comparing me to the former student), and I think he has already forgotten that it's literally my first rotation and has too high of standards.

Yesterday, before the harsh critisism, he told me that he doesn't care if I get 1 million things wrong because he just wants me to learn. So I don't really understand his method to madness. Any suggestions or ideas? Thanks

So I also started 3rd year rotations after my classmates. You need to mention this is your first rotation. You will be graded based on the expectation that you’ve had some rotations.

Second, this sounds like a classic case of physician-casual-speak being interpreted incorrectly by a medical student which happened to me as-nauseaum third year. When he says do all these things (CN exam, etc.) you basically do them quickly and don’t hyper-focus on one area. Don’t go one-by-one until you isolate the problem. Just think about what could be wrong and test whatever you think could be out of whack. The key to the history is to always figure out why they’re there. Your attending seemed to be using this as a learning case so that probably means there was a classic neurological problem. Otherwise however, the patient’s spoken “what brings you in today” requires significant modification to boil it down to the chief complaint you start your differential around.

As for the spoken vs. written H&P, they are completely different and credit Dr. Dustyn Williams of OnlineMedEd whose video you can look up to explain this. The written H&P is extremely thorough and your notes should write before presenting to the attending ONLY be thorough enough to be able to help you recall everything. Otherwise, you’re spending too much time recording when you should be thinking and organizing things in your head. You should not write everything out. Focus on what’s pertinent. As for the spoken H&P, you’re going to have to take risks. The enemy of good is perfect and that’s the case here. Trying to be perfect will lead you to include too much. What you may think is relevant is inevitably not the same as a resident/attending. If you thought to include “no XYZ” because you learnt that XYZ could indicate a rare condition you learnt in medical school, then skip it. The spoken H&P is not an exam that you need to score the most amount of points and worry about missing things. Instead it’s a game of how much you can make the attending understand in under 30 seconds to a minute. You can miss 50% of what should go in an H&P and still mail a presentation. Also, make sure the order facilitates their understanding. If the patient had a transplant, put that near the very beginning, not in the surgery section. You’ll notice that you basically skip the ROS, Medical/Surgical/Meds/Family/Social/Allergies, etc. unless one of those is pertinent to put in the written H&P

Lastly putting pressure on yourself makes things worse. Just focus on doing your best and whats out of your control will subside. It’s not about where you start, but where you end up. If you have a good attitude and genuinely want to get better, that will be the best determinant of how Succesful you are, not how fast you pick something up.

As for the language barrier/cultural difference, I don’t want to speak for one of the most diverse ethnicities where states of India speak completely different languages, have different cuisines, and different religions, but Indian IMGs have the combination of lacking an awareness of what stage AMGs progress at in addition to being more blunt which is a cultural thing(often perceived as tough love). It’s traditional to get pimped over there quite more than it is here. In this case, the attending was wrong to say your presentation was awful. That just defeats one’s morale and is out of place. When delivering criticism, the giver needs to speak softly and the onus should be on the recipient of said advice to understand and only if it’s not received should a mentor be blunt. Instead he should have said that it looks like you put a lot of effort, but you did not give an effective presentation and there are many things that you’ll need to improve on in the upcoming month That’s on him.

 

[trs88]

So I also started 3rd year rotations after my classmates. You need to mention this is your first rotation. You will be graded based on the expectation that you’ve had some rotations.

Second, this sounds like a classic case of physician-casual-speak being interpreted incorrectly by a medical student which happened to me as-nauseaum third year. When he says do all these things (CN exam, etc.) you basically do them quickly and don’t hyper-focus on one area. Don’t go one-by-one until you isolate the problem. Just think about what could be wrong and test whatever you think could be out of whack. The key to the history is to always figure out why they’re there. Your attending seemed to be using this as a learning case so that probably means there was a classic neurological problem. Otherwise however, the patient’s spoken “what brings you in today” requires significant modification to boil it down to the chief complaint you start your differential around.

Thanks, I appreciate your post. All of it was very helpful. I've jotted your key points down so hopefully I can put them into play today and try to improve things a bit.

 

[operaman]

Presentation 101:

1) use signposts. If you’re giving a full formal presentation, you should say aloud “chief complaint” and “the present illness” and “past medical history.” Your issue may just be one of staying organized. Signposts help you and the listeners remain focused.

2) Do NOT editorialize! Students love to pepper the early parts of the presentation with their own thoughts. Save those for the very end during your assessment and plan.

3) Know more, say less. Patients will wax on about things that are meaningless. They will take two minutes to tell you something that can be recounted in 5 seconds. For example, I may ask a post op what they or their child was able to eat yesterday and they will probably go into detail about each meal and snack. When I present that later, it turns into “he tolerated po” and maybe, if a child, “averaged 2oz per hour of po.” If someone wants to hear about how many sips of apple juice they had, I can tell them, but that isn’t going in my initial presentation.

It’s ok not to say everything you know. Let the attending ask you first if there’s some detail that later becomes important, and hopefully you know the answer.

4) tell a story. Like any good storyteller, you must know where your story is going. If your diagnosis is diabetic neuropathy, then you will want to be sure and include relevant info earlier in your presentation (ie. their history of diabetes and last A1c of 9.6). If my diagnosis is lumber radiculopathy, then I may leave out the diabetes info and focus on their past injury and prior spinal fusion. The goal isn’t to make them solve the case, it’s to convey relevant information efficiently.

4a: Don’t put the entire PMHx in front of your HPI. You’ll hear people do this and read notes to this effect. Don’t do it. It sucks. Only put things there that are critical for your ultimate diagnosis, such as the diabetes and the a1c mentioned above, and which also set up your story. If they have a ton a medical problems, mention that they have an extensive pay medical history when you start, but only specify the important things.

5) Memorize. Don’t use notes. If you have anything written down, write down your signposts so you don’t forget anything, but you should be able to remember a story you literally just heard minutes earlier.

6) ask your staff how they like their presentations. I have some staff who basically only want to hear my A&P and don’t even want to hear the rest. Others want something more formal. For a student, they will likely want something more formal.

7) don’t ever use the word “normal” or “benign.” Nobody thinks you know what those mean yet. Instead, describe your negative findings. Lungs don’t sound normal, they have strong symmetric breath sounds without crackles or wheezes (or whatever words you like to use).

Obviously all of these things are harder to do when you’re learning and don’t quite know what’s important and what’s not. You may not know the diagnosis or even have much of a differential which makes the above trickier. Even so, keep trying to follow the rules above and let that also guide some of your reading. Read all your attendings’ and residents’ notes about your patients and learn what you like and don’t like. Keep practicing and you’ll get it.