Intern Insubordination

[porthcurno]

I have an intern who thinks she's the queen of the hospital....telling me she "sent" the attending to go evaluate a patient for discharge, telling me to help her with discharges "since you're not doing anything" (not true). I offered to help her on call by writing some orders, and she made a big show of rewriting them so they could be in the "preferred nurse order" and ended up forgetting to add morning labs. I've seen her literally lie about ordering things before when she forgot them. She blatantly ignored me when I told her to page me so we could see new admissions together, instead paging me "hey I wrote some orders on that patient, go review them". If I tell the medical student something, she contradicts what I am saying. She never updates me on anything she is doing. I'm not sure if she's spoiled or just thinks she's better than everyone else because she got into a competitive subspecialty and is just doing her prelim...how to give this person a clue about how ridiculous she is?

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[Seijitsu]

I am sorry to hear that you are dealing with that. It is definitely a pain to deal with uncooperative people who think they are entitled. You are her senior, and she needs to understand and respect that fact.

It sounds like you have given this intern a lot of leeway. You need to strongly clarify to this intern her role as a team member. It is completely unacceptable to disregard instructions from a senior. Hopefully you can sit this intern down and honestly discuss their performance. If she is not amendable with a one on one discuss, you may have to elevate the issue to the faculty.

 

[MedPedsResident]

Feedback to the program director usually accomplishes this nicely, and won't really hurt her since she is a prelim.

 

[turquoiseblue]

I agree with Wagy. I was about to say something similar. Give her the threat of a PD and throw a mild fit, at least say something about it, when you see her being blatant. dont be compromising or give second chances. she learned this behavior by your acceptance of it and not doing anything forceful about it to stop her in her tracks. don't be mean, but be firm. just tell her the reality that you're her senior, you have a year more experience and have been in her shoes, that she do what you say or it could get her in trouble by going to the PD.

 

[lowbudget]

Do me, her, yourself, your patients, and everybody else a favor by smacking this nonsense down. I don't care if you bring the rain. You have a problem resident.

I don't care if you got into a competitive subspecialty. I don't care if you are 2nd in line to the Queen of England. If you don't pass this rotation and this prelim year, you're not going anywhere until you get it right. She needs to simmer down now.

 

[Gastrapathy]

Recommend that your attendings fail her and make sure the PD knows that you did.

Put it in terms of the ACGME core competencies.

 

[CouchPotato]

To differ a little from the above posts, she is done 7 of 12 months of intern year. If she is not hurting her patients (forgetting to order AM labs will not likely kill anyone), you could turn a blind eye or quietly offer advice or even just tell her that she is annoying the crap out of you (she certainly sounds annoying). She may have heard it already for the previous 7 months. As stated, she probably only cares for doing the bare minimum and scraping through this year. If you have serious patient care and patient safety issues, address them, otherwise you may just want to grind your teeth and bear it and certainly don't go out of your way to help her.

As a word of caution and because anecdotal evidence is the best kind, I had a senior resident when I was an intern who tried to "smack down" an insubordinate intern (he was a prelim intern destined for a surgical subspecialty). The senior resident even used phrases like "you need to learn to respect your seniors." It turned out the intern was very well-regarded by the faculty. This led to that senior resident's fellowship application eventually being discarded at our institution and he lost all letters of recommendation. I have seen this happen in other, less severe, situations as well...

 

[PlutoBoy]

To differ a little from the above posts, she is done 7 of 12 months of intern year. If she is not hurting her patients (forgetting to order AM labs will not likely kill anyone), you could turn a blind eye or quietly offer advice or even just tell her that she is annoying the crap out of you (she certainly sounds annoying). She may have heard it already for the previous 7 months. As stated, she probably only cares for doing the bare minimum and scraping through this year. If you have serious patient care and patient safety issues, address them, otherwise you may just want to grind your teeth and bear it and certainly don't go out of your way to help her.

As a word of caution and because anecdotal evidence is the best kind, I had a senior resident when I was an intern who tried to "smack down" an insubordinate intern (he was a prelim intern destined for a surgical subspecialty). The senior resident even used phrases like "you need to learn to respect your seniors." It turned out the intern was very well-regarded by the faculty. This led to that senior resident's fellowship application eventually being discarded at our institution and he lost all letters of recommendation. I have seen this happen in other, less severe, situations as well...

You wouldn´t happen to be the insubordinate intern, would you?

 

[Roofie]

Recommend that your attendings fail her and make sure the PD knows that you did.

Put it in terms of the ACGME core competencies.

Finally someone admits to using the core competencies to address personal grievances.

First off, since she got a "competitive sub-specialty," this intern is probably better than her peers or even her resident, who has just one more year's experience.

But it does look like she has some maturity issues that can be addressed informally by more aggressive means. Sit her down and tell her your concerns. She is being a diva and it is not appreciated.

Failing her by using the core competencies abuses the integrity of those evaluations. It also calls into question your own integrity when you use grades to settle scores.

Medicine is filled with egos, as we all know. It is pervasive because the system selects for high-achieving individuals. When I was in college, the pre-med advisor looked into a full auditorium and said only 1 in 8 of you present will make it to medical school. The undergraduate institution was highly ranked. So this girl made it to medical school and beat most of her peers to get the "competitive specialty". There is no doubt, she is special.

So let us assume that you take a mob mentality approach. You fail her with the worse possible evaluation. You turn her attendings against her and they fail her too. You even get the PD involved. Then the PD calls her residency and they rescind her contract. She's now untrainable and has difficulty getting any other position.

You might feel good that she got what she was due. The profession loses another talented individual who more than likely would have matured as she progressed through the training years.

Rightfully, she's angry but intelligent. She becomes a lawyer and, naturally, is recruited by plaintiff's medical malpractice firms. Given her medical training, she has an easier time picking apart physician expert defense witnesses. During her career, she succeeds in many cases. Physicians call her a traitor. But who betrayed who? Who made who?

So you feel good with yourself that you "taught her a lesson." She may have the opportunity to "teach you a lesson" a few years down the road.

The point here is that the ideals of the profession get abused by its practitioners through their personal interactions. It then becomes important to take a step back. Physicians should be on the same side. They need to resolve these differences without involving formal measures that could end careers. There will always be someone smarter who has a more prestigious job. There will always be a part of you that demands greater respect. But is it absolutely essential to the primary mission?

I would concentrate on making sure she is taking care of her patients well. If you are a man, I would tell her that she is being a diva and it is not appreciated. If you are a woman, then you may have more leeway in the terms that you use to make the message clear.

 

[Droopy Snoopy]

As a word of caution and because anecdotal evidence is the worst kind, I had a senior resident when I was an intern who tried to "smack down" an insubordinate intern (he was a prelim intern destined for a surgical subspecialty).

Fixed that for you.

Finally someone admits to using the core competencies to address personal grievances... If you are a man, I would tell her that she is being a diva and it is not appreciated.

Lying about orders, forgetting labs, undermining your seniors. Do those things not fit into the core competencies somewhere (Professionalism, Interpersonal relationships, patient care)? OP if you feel like the right thing to do regarding your patients is to squash this attitude then you should absolutely do so. Nevermind the possible consequences on some possible future fellowship, turning the intern into a rabid malpractice attorney, or whatever other hypothetical nonsense that's been posted here.

 

[AmoryBlaine]

Involve the attending now and tell them your concerns.

You're the senior, you're responsible. People skate through medicine with all sorts of problems until someone has the balls to deliver the smackdown.

One thing you ABSOLUTELY need to do is make sure that every single one of your future interactions with this person is completely professional and preferably witnessed (to the extent they can be). If you talk with her I would advise doing it in front of your attending.

The reason I say this is that people with egos tend to respond extremely poorly to criticism and she may come back to your superiors with multiple complaints against you. So you need to let your superiors know ahead of time that you are concerned and that you are going to speak to her and ask one of them to be present.

I would make the end of that meeting a clear statement of her role and responsibilities i.e. "you will do all of the discharge summaries unless I offer to help you, you will not 'give me orders' at any time."

 

[Substance]

If I tell the medical student something, she contradicts what I am saying.

Are you ever actually wrong? If you are, she did the right thing by correcting you.

 

[PlutoBoy]

Are you ever actually wrong? If you are, she did the right thing by correcting you.

I bet he was wrong and is ashamed the intern had to correct him. People throw rocks at things that shine.

 

[SouthernSurgeon]

I love the theorizing that because the intern is going into a subspecialty that they are better/smarter than their senior resident.

If what the OP says is true, the intern's behaviors show nothing of that intelligence or superior skill. It may seem like forgetting morning labs is "no big deal", but if you mess up the little things who is to say you are getting the big ones right...and lying to cover your mistakes is one of the few "unforgivable" things an intern can do.

 

[wild0ne]

Finally someone admits to using the core competencies to address personal grievances.
....
Failing her by using the core competencies abuses the integrity of those evaluations. It also calls into question your own integrity when you use grades to settle scores.
...
You might feel good that she got what she was due. The profession loses another talented individual who more than likely would have matured as she progressed through the training years.
...
The point here is that the ideals of the profession get abused by its practitioners through their personal interactions. It then becomes important to take a step back. Physicians should be on the same side. They need to resolve these differences without involving formal measures that could end careers. There will always be someone smarter who has a more prestigious job. There will always be a part of you that demands greater respect. But is it absolutely essential to the primary mission?

I would concentrate on making sure she is taking care of her patients well. If you are a man, I would tell her that she is being a diva and it is not appreciated. If you are a woman, then you may have more leeway in the terms that you use to make the message clear.

Excellent post. Sadly, your opinion seems to be in the minority.

 

[smq123]

Excellent post. Sadly, your opinion seems to be in the minority.

I find it concerning that there is this blind belief that "the resident is always the victim" that people are ignoring that the intern in question LIES about what orders she put in, and, because of her attitude, forgets to order morning labs for patients.

In case people have forgotten what the core competencies include, they include patient care, professionalism, and communication. Forgetting to order labs, purely because your spiteful attitude leads you to unnecessarily redo orders, is hardly good patient care. Lying about what orders you put in is clearly unprofessional, and not running things by the rest of your team (regardless of hierarchy) is poor communication. These aren't just core competencies, these are stuff that all physicians should be doing.

 

[anonperson]

Finally someone admits to using the core competencies to address personal grievances.

First off, since she got a "competitive sub-specialty," this intern is probably better than her peers or even her resident, who has just one more year's experience.

But it does look like she has some maturity issues that can be addressed informally by more aggressive means. Sit her down and tell her your concerns. She is being a diva and it is not appreciated.

Failing her by using the core competencies abuses the integrity of those evaluations. It also calls into question your own integrity when you use grades to settle scores.


Rightfully, she's angry but intelligent. She becomes a lawyer and, naturally, is recruited by plaintiff's medical malpractice firms. Given her medical training, she has an easier time picking apart physician expert defense witnesses. During her career, she succeeds in many cases. Physicians call her a traitor. But who betrayed who? Who made who?



I would concentrate on making sure she is taking care of her patients well. If you are a man, I would tell her that she is being a diva and it is not appreciated. If you are a woman, then you may have more leeway in the terms that you use to make the message clear.

This post is a bit overdramatic.

From what the OP has stated, the intern has seemingly violated many of the core competancies in terms of patient care, integrity/professionalism etc.

We're only getting one side of the story but the intern sounds like a pain in the ass. There is a hierarchy in medicine that should be respected.

She probably is very intelligent but it's not an excuse to being lazy and taking advantage of a situation.

What I find somewhat concerning about her is that she can't even keep it together for 1 year knowing that there is a light at the end of the tunnel. She's probably gotten into the residency of her choice and she knew she'd be doing an intern year. This isn't a surprise. Somehow, I doubt she will magically change into a model resident once she's done here. I really don't want to see what type of upper level resident she will be when she's exhibiting this behavior so early in the game.

To the OP: Nip the behavior in the bud sooner rather than later. Don't let it become personal because it isn't. This is a matter of an intern conducting themselves in a professional manner and getting their #hit done. Involve your PD if you aren't getting through to her one on one but trread carefully. You don't want her to paint you as being "out to get her"

 

[danielmd06]

This ludicrous notion of entitlement seems to be becoming more frequent in the past 5 years. Anyway.

From time to time...I've had to lock horns with someone over silliness like this. Entitled medical students, jerk seniors/fellows, and insubordinate junior residents come with the territory of what we do. It also comes with the turf if you want to be a good Chief Resident. Prime rule for dealing with this junk: just brush it off your shoulders and be the bigger person.

If this isn't working and you cannot seem to ignore it then here's a bit of advice...

First ask yourself...is this worth fighting over with 5 months left? It's probably not. Most of what you describe quite frankly gives the impression of just plain old personality mismatch. Very little of what you describe seems to implicate gross insubordination or unprofessionalism. Lying should never be tolerated.

Anyway, if you deem this worth the battle, then I would proceed in this order:

1) Privately take her aside and explain the problems you're having with her. Explain any patient safety concerns you have. Explain any communication issues you have. Sympathize with her work load. Remind her you've been there. Offer to help when you can...but be clear that the final responsibility for chores like discharging patients ultimately and unequivocally resides with her. A little niceness goes a long way...BUT your intern has no business "telling" you to help her with discharges. It's her job. Full stop. End of sentence. Tell your Chief that you've had to have this talk with the intern.

2) If she is not compliant with your requests after you politely discuss these things with her, then have your Chief Resident remind her that her call schedule can be manipulated to punish her for lying. Patient safety comes first. You have to be able to trust people. Lying is about the only thing you mention that seems offensive enough (to me) to threaten this intern over.

3) If a punitive call schedule doesn't straighten things out (and I CAN'T believe it wouldn't) then go inform an attending (in authority over the residents) if you continue to have problems. Bring documentation of events. Make sure it's worth bugging an attending about. This measure is a last resort.

Remember...attendings are like parents with children. They don't care about who's right or wrong. They don't care about abstractions like "justice." They care about peace and quiet and keeping the machine running smoothly enough so that they are spared the headaches of day-to-day inpatient nonsense.

For the record, I never, ever asked an attending for help with a discipline case.

People who are suggesting you need to flunk the intern or sabotage her career are going a bit overboard. Most of us have behaved like jerks at some point. Just make sure the patients are staying safe.

Good luck.

 

[turquoiseblue]

i don't believe in being heirarchical toward people, but when you are liable for the things she does, then you do want to make sure she is obedient to the way you want things done.

actually when i make mistakes, the residents just report me right then and there behind my back. no warning, not even nice about it. so you could do that too. but i thought it wasn't fair to not give a warning.

 

[MrBurns10]

danielmd is right on this one. She's obviously in the wrong here, but if you- or any of other upper levels she may have had- haven't even talked to her about her behavior, frankly she's not to blame for not correcting it...because she may not even realize the things she's doing are inappropriate (except for lying, which is never okay). I'm a prelim at a small medicine program and intra-residency relations sucks. People have a problem with something, they automatically go to the chief resident or attending/PD when the mature thing to do is to first talk to them directly about it. Then, if that doesn't bring about a change in behavior, you take it to the next level (usually the chief).

Give her a chance to change before you go trying to ruin her evaluations or, like others seem to have suggested, possibly her career.

 

[porthcurno]

Thanks for the varied and detailed posts. I can't fail this person, but I do plan to give low scores for professionalism, and speak to one of the program directors. (the other day, she decided someone needed a Pap smear (an INPATIENT), and later asked me "Did you take care of that?")I think my tack when she asks me to do work for her again will be "The other interns seem to take care of their own tasks. Why can't you?". I asked one of the other residents about her. She hasn't worked with the person but says "I see her bossing residents around".

In response to the questions about whether the intern was correct and I was wrong about something, the issues seem to arise from medical decision making which is black and white to a memorizing medical student, but gray to someone who has actually spent serious time in the hospital. So she repeatedly spits out the same assertion over and over even if someone else is telling her it's not necessarily correct in the real world. So. Incredibly. Annoying.

 

[dragonfly99]

I agree w/danielMD and MrBurns.
The intern seems to have some interpersonal relations issues, and probably maturity issues. However, we are only getting 1 side of the story. These things are rarely worth getting super upset about. You only have to work with each person for 1 month/year, usually. You can always poison her evaluation, like you are planning to do, but don't go off the deep end. Also, ask yourself if you would give a similarly bad evaluation to an intern who didn't annoy you, but made serious patient care mistakes or had a really poor level of knowledge. I think those last types tend to skate by, and are very likely more dangerous/worse docs in the long run.
However, I do agree that the intern bossing around other people is clearly not appropriate.

 

[Apollyon]

This ludicrous notion of entitlement seems to be becoming more frequent in the past 5 years. Anyway.

I dealt with it 9 years ago.

When I was prelim IM, there was one guy that was select for ophtho PGY-2, but didn't match for prelim and had to scramble. He was HORRIBLE. He wouldn't answer his pages, and nearly got fired for it. When he did answer them, he was the worst person in the world to the nurses; it got to the point that they would page ME, because I was nice, about his patients. That was a pain in the tuches. Ours was a rare program where prelims had clinic. He was such a schmuck, he just wouldn't go, because he knew his patients wouldn't show up to see him.

Talking to this guy, he would turn everything to posterior segment surgery and the retina. You could talk about Nanakuli, Hawai'i, and he would somehow, within a minute, bring it to the retina. It was remarkable.

He tightened up a bit in the last 4 months, after being called on the carpet, told he would be fired, which would cancel his ophtho contract, and he'd be out of luck. Even though he was Jewish, and the program director was Jewish, and the hospital was Jewish, there was no pipeline. No preference/no "tribe" thing. He was clearly told what was the score, and he was honestly "scared straight". And the boss would have canned him, without a doubt.

 

[wine thief]

Even though he was Jewish, and the program director was Jewish, and the hospital was Jewish, there was no pipeline. No preference/no "tribe" thing.

Wow. What a bizarre comment. Conspiracy theory much?

 

[Apollyon]

Wow. What a bizarre comment. Conspiracy theory much?

Bizarre? Really? Have you ever been to a religiously oriented hospital? Mt. Sinai, Maimonides, Castle Medical Center, Loma Linda University? Whether you know it or not, it happens. However, it didn't in this case.

 

[Woot!]

Bizarre? Really? Have you ever been to a religiously oriented hospital? Mt. Sinai, Maimonides, Castle Medical Center, Loma Linda University? Whether you know it or not, it happens. However, it didn't in this case.

The only time Jews get more preference is for the shomer shabbos spots. If anything, the Jewish attendings give a MUCH harder time and expect even MORE from their own tribe.

If a Jew makes a fool of himself Jewish hospitals are SWIFT in their actions against this person and DO NOT give any special treatement.

 

[GreatSaphenous]

First off, since she got a "competitive sub-specialty," this intern is probably better than her peers or even her resident, who has just one more year's experience.

Medicine is filled with egos, as we all know. It is pervasive because the system selects for high-achieving individuals. When I was in college, the pre-med advisor looked into a full auditorium and said only 1 in 8 of you present will make it to medical school. The undergraduate institution was highly ranked. So this girl made it to medical school and beat most of her peers to get the "competitive specialty". There is no doubt, she is special.

You might feel good that she got what she was due. The profession loses another talented individual who more than likely would have matured as she progressed through the training years.

Come on! Every year people match into residencies they have no business being in. The outcome of the flitting levity that is the match in no way means that said intern is "better," "special," or "talented." If she truly believes she is any of those things (and someone who orders her superiors around while neglecting her own responsibilities would tend to think too highly of herself), she is unlikely to just mature out of it. This isn't just a training issue, how would such a special gift to medicine treat those colleagues in the "lesser specialities."

"Youth ages, immaturity is outgrown, ignorance can be educated, and drunkenness sobered, but stupid lasts forever."

All for now, go back to your cheese tortellini,
I am the Great Saphenous!!!!

 

[wild0ne]

I find it concerning that there is this blind belief that "the resident is always the victim" that people are ignoring that the intern in question LIES about what orders she put in, and, because of her attitude, forgets to order morning labs for patients.

In case people have forgotten what the core competencies include, they include patient care, professionalism, and communication. Forgetting to order labs, purely because your spiteful attitude leads you to unnecessarily redo orders, is hardly good patient care. Lying about what orders you put in is clearly unprofessional, and not running things by the rest of your team (regardless of hierarchy) is poor communication. These aren't just core competencies, these are stuff that all physicians should be doing.

No one is denying this intern is deficient in the core competencies, and requires guidance. However, bringing the "smackdown" and recommending that attendings "fail her" is excessive.

A more graduated response, as danielmd06 and Roofie outlined, demonstrates much more discipline and maturity. Hopefully, those characteristics may even rub off on her.

 

[LeemerDO]

Ever try the passive aggressive approaches to keeping lowly little miscreants like this in line?

You are well within your rights to expect an H&P written to your exact specifications. This also includes having them rewrite and dictate the entire thing over.

Stacking admits is also a favorite, especially towards the end of the day. It works even better if you know they have some other personal appointment they have to tend to. I recommend this be done about 45 minutes prior to the end of the shift. If they do it, then they'll be miserable and be late for their own thing. If they refuse, you have cause for write up for insubordination. If they just flat out don't do it and leave, then report them for delay of service. It's better to time this well with the ER.

Call is where you can really torture them. Nurses can help immensely. It may however require a bribe of ordering in dinner. Nitpick at orders written, and have them called for the most trivial of things.

Post call is where the most effective fun can occur. You can always wake them up about 1pm and chew them out for something they did the previous night. This has a dual effect of first disrupting their sleep, but also get them agitated enough that they can't go back to sleep. This is better when it's early on in the week. The rest of the week if well played, will be hellacious for them.

Phantom paging of course is another effective, albeit juvenile way of torment.

You could also mandate that the intern check in with you every hour and also be ready to receive new tasks to be done at each call.

The tried and true is however, the "reading assignment." Give'em the DDX of syncope, have them be ready to report in the morning, don't mention a thing about it at morning, and them two or three days later, when they're caught off guard, have them present it.

There are so many other ways to mess with interns aside from threatening to fail them. Why go nuclear on them for a moment, when it's so much better to roast them slowly over the year. Plus, If you're gonna want to get someone axed, pile up the crap on them before the turn of the year, preferably by February. That way, when March comes, that's usually the time the programs get their funding secured, regardless of completion and typically, problem children go bye bye.

 

[Droopy Snoopy]

Ever try the passive aggressive approaches to keeping lowly little miscreants like this in line?

You are well within your rights to expect an H&P written to your exact specifications. This also includes having them rewrite and dictate the entire thing over.

Stacking admits is also a favorite, especially towards the end of the day. It works even better if you know they have some other personal appointment they have to tend to. I recommend this be done about 45 minutes prior to the end of the shift. If they do it, then they'll be miserable and be late for their own thing. If they refuse, you have cause for write up for insubordination. If they just flat out don't do it and leave, then report them for delay of service. It's better to time this well with the ER.

Call is where you can really torture them. Nurses can help immensely. It may however require a bribe of ordering in dinner. Nitpick at orders written, and have them called for the most trivial of things.

Post call is where the most effective fun can occur. You can always wake them up about 1pm and chew them out for something they did the previous night. This has a dual effect of first disrupting their sleep, but also get them agitated enough that they can't go back to sleep. This is better when it's early on in the week. The rest of the week if well played, will be hellacious for them.

Phantom paging of course is another effective, albeit juvenile way of torment.

You could also mandate that the intern check in with you every hour and also be ready to receive new tasks to be done at each call.

The tried and true is however, the "reading assignment." Give'em the DDX of syncope, have them be ready to report in the morning, don't mention a thing about it at morning, and them two or three days later, when they're caught off guard, have them present it.

There are so many other ways to mess with interns aside from threatening to fail them. Why go nuclear on them for a moment, when it's so much better to roast them slowly over the year. Plus, If you're gonna want to get someone axed, pile up the crap on them before the turn of the year, preferably by February. That way, when March comes, that's usually the time the programs get their funding secured, regardless of completion and typically, problem children go bye bye.

Good lord, please don't ever let me land on your bad side.

 

[CandidateofDerm]

Ever try the passive aggressive approaches to keeping lowly little miscreants like this in line?

You are well within your rights to expect an H&P written to your exact specifications. This also includes having them rewrite and dictate the entire thing over.

Stacking admits is also a favorite, especially towards the end of the day. It works even better if you know they have some other personal appointment they have to tend to. I recommend this be done about 45 minutes prior to the end of the shift. If they do it, then they'll be miserable and be late for their own thing. If they refuse, you have cause for write up for insubordination. If they just flat out don't do it and leave, then report them for delay of service. It's better to time this well with the ER.

Call is where you can really torture them. Nurses can help immensely. It may however require a bribe of ordering in dinner. Nitpick at orders written, and have them called for the most trivial of things.

Post call is where the most effective fun can occur. You can always wake them up about 1pm and chew them out for something they did the previous night. This has a dual effect of first disrupting their sleep, but also get them agitated enough that they can't go back to sleep. This is better when it's early on in the week. The rest of the week if well played, will be hellacious for them.

Phantom paging of course is another effective, albeit juvenile way of torment.

You could also mandate that the intern check in with you every hour and also be ready to receive new tasks to be done at each call.

The tried and true is however, the "reading assignment." Give'em the DDX of syncope, have them be ready to report in the morning, don't mention a thing about it at morning, and them two or three days later, when they're caught off guard, have them present it.

There are so many other ways to mess with interns aside from threatening to fail them. Why go nuclear on them for a moment, when it's so much better to roast them slowly over the year. Plus, If you're gonna want to get someone axed, pile up the crap on them before the turn of the year, preferably by February. That way, when March comes, that's usually the time the programs get their funding secured, regardless of completion and typically, problem children go bye bye.

Ever try the passive aggressive approaches to keeping lowly little miscreants like this in line?

You are well within your rights to expect an H&P written to your exact specifications. This also includes having them rewrite and dictate the entire thing over.

Stacking admits is also a favorite, especially towards the end of the day. It works even better if you know they have some other personal appointment they have to tend to. I recommend this be done about 45 minutes prior to the end of the shift. If they do it, then they'll be miserable and be late for their own thing. If they refuse, you have cause for write up for insubordination. If they just flat out don't do it and leave, then report them for delay of service. It's better to time this well with the ER.

Call is where you can really torture them. Nurses can help immensely. It may however require a bribe of ordering in dinner. Nitpick at orders written, and have them called for the most trivial of things.

Post call is where the most effective fun can occur. You can always wake them up about 1pm and chew them out for something they did the previous night. This has a dual effect of first disrupting their sleep, but also get them agitated enough that they can't go back to sleep. This is better when it's early on in the week. The rest of the week if well played, will be hellacious for them.

Phantom paging of course is another effective, albeit juvenile way of torment.

You could also mandate that the intern check in with you every hour and also be ready to receive new tasks to be done at each call.

The tried and true is however, the "reading assignment." Give'em the DDX of syncope, have them be ready to report in the morning, don't mention a thing about it at morning, and them two or three days later, when they're caught off guard, have them present it.

There are so many other ways to mess with interns aside from threatening to fail them. Why go nuclear on them for a moment, when it's so much better to roast them slowly over the year. Plus, If you're gonna want to get someone axed, pile up the crap on them before the turn of the year, preferably by February. That way, when March comes, that's usually the time the programs get their funding secured, regardless of completion and typically, problem children go bye bye.

This thread makes me sick to my stomach. You guys would give someone advice in a position of power to destroy another person's career without knowing both sides. On top of that, it sounds like this is all phrasing. I am struggling to get my work done, can you help me with discharges versus you help me with discharges. Have you done the pap smear versus I haven't done a pap smear since I was a third year and I need help doing a pap smear. How do you know that she doesn't like to enter her own orders so things don't get left out, thereby when you do this is leads her to forget to do things that she thinks got done making her look like a liar. Always give people the benefit of the doubt.

Part of being an upper level is learning how to manage people because you will be doing it the rest of your career. If you can now resolve this conflict it reflects poorly upon you. First, you need to tell the intern that she is not doing well. Offer specific examples and how she can be specifically do well. If she continues to do poorly then talk with her again. Specific examples and specific suggestions. Tell her if she improves it will not go in her record. IF it continues then leave some comments in her eval. Do not torch her. DO not go chief resident or PD unless she is literally going to killa patient.

Finally, never go play in the mud or else you will get dirty. All those passive aggressive maneuveurs not only hurt a fellow human being who may be struggling in their toughest year of their life, but also directly lead to hurting patients. How would you like you grandma to the one purposely stacked onto three other admissions in the late afternoon when she probably needed to be seen earlier, but now she is going to get poor care due to an fraveled intern. I guess you will accomplish your goal when the intern kills a patient and gets in trouble. Remember though, you will probably get in trouble to bc you are the manager and you will still have to write a discharge summary for that patient. I think what you are aiming for though is sleep depriving the intern enough to where there is suicide in your program. This won't reflect well on you or your program though. Remember, we are not playing internet games here. Advice you give to people in power have real and unintentional consequences. I hope you can live with yours.

 

[Law2Doc]

... If she is not hurting her patients (forgetting to order AM labs will not likely kill anyone)...

Not really a true statement, at least for a lot of services. A dropping crit or skyrocketing potassium is kind of important to know about sooner rather than later.

 

[reedman]

sorry if i'm out of my element here.

question: will this intern recieve some kind of letter of rec or evaluation that someone at her specialty program will read? if this is the case, shouldn't she be made aware that she is not playing well with others so that she has time to correct her behavior before this letter is written?

 

[Gastrapathy]

This person has already matched for next year. When I've seen cases like this, negative but passing evals have no effect. A rotation failure with required remediation is an extremely effective wake up call. The trainee loses her precious elective month to remediate the rotation and knows that from then on, further failures will risk her residency.

We're so afraid of ever saying someone doesn't meet the standard. "always give the benefit of the doubt" "don't torch her" "using the core competencies to address personal grievences" etc. All of this misses the point. She is not meeting the basic professionalism standards from the perspective of her closest supervisor. That supervisor has a basic responsibility to decide whether her professionalism issues fall below a passing standard. This decision will not be made in a vacuum but having the courage to recommend that someone fail a rotation is not inherently wrong.

The passive-aggressive stuff I hope was tongue-in-cheek. If I ever discovered a resident was playing those kind of games to punish an intern, that resident would suffer.

 

[reedman]

then perhaps a "come to jesus" meeting is in order? somebody needs to tell her something, for social and professional reasons.

 

[CandidateofDerm]

This person has already matched for next year. When I've seen cases like this, negative but passing evals have no effect. A rotation failure with required remediation is an extremely effective wake up call. The trainee loses her precious elective month to remediate the rotation and knows that from then on, further failures will risk her residency.

We're so afraid of ever saying someone doesn't meet the standard. "always give the benefit of the doubt" "don't torch her" "using the core competencies to address personal grievences" etc. All of this misses the point. She is not meeting the basic professionalism standards from the perspective of her closest supervisor. That supervisor has a basic responsibility to decide whether her professionalism issues fall below a passing standard. This decision will not be made in a vacuum but having the courage to recommend that someone fail a rotation is not inherently wrong.

The passive-aggressive stuff I hope was tongue-in-cheek. If I ever discovered a resident was playing those kind of games to punish an intern, that resident would suffer.

I don't know. Read the ops initial post. Besides the point where she says that she has caught her at point lying (which might be an honest mistake when you enter in literally 100s of orders a day), none of that sounds like grounds for serious action. If anything it sounds like poor communication between a resident and intern.

My bet is that if you tried to accuse teh intern of being below passing, the intern will probably counter that you are absent, do not help the intern with the workload, and overall are not a good resident. They will probably say it is impossible to keep you updated because you are absent and not supervising them properly. At this point, you better hope that the intern has bad reviews from other people or else it will turn into your word against hers leading to a black eye against you as well as her.

Read the initial post. It sounds so petty. The op hasn't even told her there is a problem, yet your initial step is to make her remediate a month and possibly try to kick her out of residency! What is she doesn't have an elective month left to remediate with! I guess we can all see where those malignant attendings come from that out of the blue kick people out of programs. I hope you never have a supervisor that feels you don't communicate well because this can be a very subjective metric.

TALK with the intern!!! Be nice, be pleasant! Be a good person and I promise everything will work out for the best. Act with moderation and never in extremes and life will treat you well. Be a nice, reasonable person and good things will happen. You can always do more later if things get worse, but you can't always take back things that you have done. If I know knew you better, I would bet that in a month when you are out fo the heat of moment, you will think this was all pretty silly... don't lose the forest for the trees.

 

[LeemerDO]

This person has already matched for next year. When I've seen cases like this, negative but passing evals have no effect. A rotation failure with required remediation is an extremely effective wake up call. The trainee loses her precious elective month to remediate the rotation and knows that from then on, further failures will risk her residency.

We're so afraid of ever saying someone doesn't meet the standard. "always give the benefit of the doubt" "don't torch her" "using the core competencies to address personal grievences" etc. All of this misses the point. She is not meeting the basic professionalism standards from the perspective of her closest supervisor. That supervisor has a basic responsibility to decide whether her professionalism issues fall below a passing standard. This decision will not be made in a vacuum but having the courage to recommend that someone fail a rotation is not inherently wrong.

The passive-aggressive stuff I hope was tongue-in-cheek. If I ever discovered a resident was playing those kind of games to punish an intern, that resident would suffer.

Well, most of it was tongue in cheek. I won't say which parts. Of course, most of those suggestions although they do cause inconvenience and added burden, they do not overall debilitate, but can potentially serve to enhance an intern's knowledge and level of responsibility and accountability. I know the call torment tactics are just plain sadistic. So, use with caution and preferably on the refractory hopeless causes. Believe me, there are those that are deserving of that swift kick. But then again, come next year, new intern rules go into effect, so most of those suggestions go nil after this academic year anyways.

In my experience, it was actually the program director who was ineffective and failed to follow through in actual enforcement. His (or her) involvement in the program was affable and statutory at best. So when I have no other recourse, then I do what needs to be done, and of course within reason and within the parameters of what's allowed.

 

[LeemerDO]

Finally, never go play in the mud or else you will get dirty. All those passive aggressive maneuveurs not only hurt a fellow human being who may be struggling in their toughest year of their life, but also directly lead to hurting patients. How would you like you grandma to the one purposely stacked onto three other admissions in the late afternoon when she probably needed to be seen earlier, but now she is going to get poor care due to an fraveled intern. I guess you will accomplish your goal when the intern kills a patient and gets in trouble. Remember though, you will probably get in trouble to bc you are the manager and you will still have to write a discharge summary for that patient. I think what you are aiming for though is sleep depriving the intern enough to where there is suicide in your program. This won't reflect well on you or your program though. Remember, we are not playing internet games here. Advice you give to people in power have real and unintentional consequences. I hope you can live with yours.

Judging by the OP's story, I really don't think that this intern is having the most hellish year of her life. In actuality, I think it's a complete role reversal. She's causing more pain to other people, attendings included, by having the rest of her program tolerate her behavior with no consequence. Plus, the intern experience is only going to get "easier" and I use that term very loosely by the way, since they will no longer have that overnight call responsibility. So rest assured, I speak of things of an even further bygone era.

 

[CandidateofDerm]

Judging by the OP's story, I really don't think that this intern is having the most hellish year of her life. In actuality, I think it's a complete role reversal. She's causing more pain to other people, attendings included, by having the rest of her program tolerate her behavior with no consequence. Plus, the intern experience is only going to get "easier" and I use that term very loosely by the way, since they will no longer have that overnight call responsibility. So rest assured, I speak of things of an even further bygone era.

Wow. You must have amazing gifts of intuition to be able to gleen from the ops initial post that this intern is having an easy year and not only that, but she is making everyone else's life a living hell other than the ops with Freaky Friday Role Reversal! Oh no, the resident has woken up inside the body of the intern and now has to do absolutely everything. I wish I could read inbetween the lines as well as you. I don't recall the op even saying what their call schedule is or how many hours they are working. For all you know, they are on a q3 call schedule during this rotation. You don't know squat about this situation,but you make assumptions over and over!

Do you ever look in the mirror and wonder how you became that stereotype physician who complains about how things were different and better as people no longer work as hard as you did? If you are the product that the old call system has created, then thank the lord for a new system. Clearly, your underhanded tactics post was not in jest and you HAVE actually done these things as "In my experience, it was actually the program director who was ineffective and failed to follow through in actual enforcement." Have you ever stopped to think that maybe the program director just plain didn't agree with you? No, that couldn't be it.

 

[PlutoBoy]

Wow. You must have amazing gifts of intuition to be able to gleen from the ops initial post that this intern is having an easy year and not only that, but she is making everyone else's life a living hell other than the ops with Freaky Friday Role Reversal! Oh no, the resident has woken up inside the body of the intern and now has to do absolutely everything. I wish I could read inbetween the lines as well as you. I don't recall the op even saying what their call schedule is or how many hours they are working. For all you know, they are on a q3 call schedule during this rotation. You don't know squat about this situation,but you make assumptions over and over!

Do you ever look in the mirror and wonder how you became that stereotype physician who complains about how things were different and better as people no longer work as hard as you did? If you are the product that the old call system has created, then thank the lord for a new system. Clearly, your underhanded tactics post was not in jest and you HAVE actually done these things as "In my experience, it was actually the program director who was ineffective and failed to follow through in actual enforcement." Have you ever stopped to think that maybe the program director just plain didn't agree with you? No, that couldn't be it.

 

[Dawn1980]

Ever try the passive aggressive approaches to keeping lowly little miscreants like this in line?

You are well within your rights to expect an H&P written to your exact specifications. This also includes having them rewrite and dictate the entire thing over.

Stacking admits is also a favorite, especially towards the end of the day. It works even better if you know they have some other personal appointment they have to tend to. I recommend this be done about 45 minutes prior to the end of the shift. If they do it, then they'll be miserable and be late for their own thing. If they refuse, you have cause for write up for insubordination. If they just flat out don't do it and leave, then report them for delay of service. It's better to time this well with the ER.

Call is where you can really torture them. Nurses can help immensely. It may however require a bribe of ordering in dinner. Nitpick at orders written, and have them called for the most trivial of things.

Post call is where the most effective fun can occur. You can always wake them up about 1pm and chew them out for something they did the previous night. This has a dual effect of first disrupting their sleep, but also get them agitated enough that they can't go back to sleep. This is better when it's early on in the week. The rest of the week if well played, will be hellacious for them.

Phantom paging of course is another effective, albeit juvenile way of torment.

You could also mandate that the intern check in with you every hour and also be ready to receive new tasks to be done at each call.

The tried and true is however, the "reading assignment." Give'em the DDX of syncope, have them be ready to report in the morning, don't mention a thing about it at morning, and them two or three days later, when they're caught off guard, have them present it.

There are so many other ways to mess with interns aside from threatening to fail them. Why go nuclear on them for a moment, when it's so much better to roast them slowly over the year. Plus, If you're gonna want to get someone axed, pile up the crap on them before the turn of the year, preferably by February. That way, when March comes, that's usually the time the programs get their funding secured, regardless of completion and typically, problem children go bye bye.

Unfortunately, I had a surgery pre-lim (intern) employ these tactics on me when I was a 3rd year medical student on my first two weeks of the Surgery rotation. He told me on Day 1 that I was a woman, my place was in the kitchen (exact words - he was from a strict religious university), and since I wanted to play with the "big boys," I had better "be prepared." I endured a lot of the aforementioned passive-aggressive tactics along with others (i.e. paging me to perform every rectal exam and laughing at me afterward, pimping me on the four classical signs of inflammation in the middle of a trauma, paging me to perform manual disimpactions, paging me in the middle of the night "just because"). His power trip was completely tortuous.

Anyhow, as you can guess, I don't recommend passive-aggressive tactics. Passive-aggressiveness is very cowardly. Just talk to the intern (let her know there is a problem, b/c she probably doesn't know), and if changes aren't made, then move up from there.

 

[Ronin2258]

I dealt with it 9 years ago.

When I was prelim IM, there was one guy that was select for ophtho PGY-2, but didn't match for prelim and had to scramble. He was HORRIBLE. He wouldn't answer his pages, and nearly got fired for it. When he did answer them, he was the worst person in the world to the nurses; it got to the point that they would page ME, because I was nice...

He tightened up a bit in the last 4 months, after being called on the carpet, told he would be fired, which would cancel his ophtho contract, and he'd be out of luck...

Had an intern like that when I was a junior resident. Scramble to get into internship. Same thing with me re: Nurses calling for patient help, etc. He was about as obvious as the guy you described. He was called to the PDs office a few times. He managed to survive it with some minor improvements. Though he was a royal pain in the semperini to deal with at times.

Ever try the passive aggressive approaches to keeping lowly little miscreants like this in line?...

Good lord, please don't ever let me land on your bad side.

I second this remark. And as much as this would appeal to me, better judgement and sense of team unity keeps me from doing this.


As for the OP, I suggest a stepwise approach.
1. Solve at the lowest level. That means telling the directly to shape up.
2a. Report to the next level, i.e., senior residents.
2b. Inform your seniors and hold a conversation with her peers and her. The term from the military is "wall-to-wall discussion," where it is the peers line up against the walls with the person in the center, telling the problem person how to correct the faults (very important to be constructive in this one. Offer solutions.)
4. Report to the attendings.

Option 2b can be dicey. It can be an "everyone is against me" attitude that might shut them down. In the military, it tends to work better, as there is a more formal hierarchy with some respect towards the team, which the person in question sounds like they don't have. In civilian life, this may practically means that 1, 2a, and 3 are the only steps.

It sounds like she needs some serious carpet time. Her subspecialty's instructors will crucify her. If she spouts this attitude with you, what makes you think she is going to breeze through her chosen specialty? This type of attitude is not easily covered up or put away when stressed (seen it attempted.) Not being a team player in this profession is going to box someone. Better a firm correction now than having her really screw up later.

 

[476515678234896]

Ever try the passive aggressive approaches to keeping lowly little miscreants like this in line?

You are well within your rights to expect an H&P written to your exact specifications. This also includes having them rewrite and dictate the entire thing over.

Stacking admits is also a favorite, especially towards the end of the day. It works even better if you know they have some other personal appointment they have to tend to. I recommend this be done about 45 minutes prior to the end of the shift. If they do it, then they'll be miserable and be late for their own thing. If they refuse, you have cause for write up for insubordination. If they just flat out don't do it and leave, then report them for delay of service. It's better to time this well with the ER.

Call is where you can really torture them. Nurses can help immensely. It may however require a bribe of ordering in dinner. Nitpick at orders written, and have them called for the most trivial of things.

Post call is where the most effective fun can occur. You can always wake them up about 1pm and chew them out for something they did the previous night. This has a dual effect of first disrupting their sleep, but also get them agitated enough that they can't go back to sleep. This is better when it's early on in the week. The rest of the week if well played, will be hellacious for them.

Phantom paging of course is another effective, albeit juvenile way of torment.

You could also mandate that the intern check in with you every hour and also be ready to receive new tasks to be done at each call.

The tried and true is however, the "reading assignment." Give'em the DDX of syncope, have them be ready to report in the morning, don't mention a thing about it at morning, and them two or three days later, when they're caught off guard, have them present it.

There are so many other ways to mess with interns aside from threatening to fail them. Why go nuclear on them for a moment, when it's so much better to roast them slowly over the year. Plus, If you're gonna want to get someone axed, pile up the crap on them before the turn of the year, preferably by February. That way, when March comes, that's usually the time the programs get their funding secured, regardless of completion and typically, problem children go bye bye.

This kind of stuff disgusts me. Does this really happen?

Why not just man up and talk to the intern and tell them that they're not meeting your expectations instead of hiding like a mouse behind your authority? This kind of hazing seems more fitting for the military or a fraternity, not a professional career with arguably one of the most important jobs around.

There are so many other ways to mess with interns aside from threatening to fail them.

I don't get why you need to "mess" with them. If there work is sub-par why not let them know? and why not have clear cut expectations for what they should expect if they do not meet a certain standard? The ramifications for being sub-par (or unlikable) seem to be reminiscent of a 5th grade schoolyard bully, victimizing a 4th graderer because there was a one year difference in their age. Even a secretary or plumber gets treated with more respect than this.

 

[dpmd]

The term from the military is "wall-to-wall discussion," where it is the peers line up against the walls with the person in the center, telling the problem person how to correct the faults (very important to be constructive in this one. Offer solutions.)

As an aside, when I was in the Army, the implication was that a wall to wall counseling session was going to involve your superior throwing you from one wall to the other until you shaped the hell up. I never received one or gave one so I guess your way might be more accurate (less of a deterrant to bad behavior than mine, I think )

More on topic, people can be enormously clueless about how they are viewed by others. A calm, direct "you are messing up by doing/not doing X, Y, Z" or "you are responsible for these tasks, I expect you to be able to do them without directing your seniors to complete them" will go a lot further than just being passive aggressive. If they don't know why they are being messed with, they may just decide you are a dick and not change. Once the direct technique has failed-and it will for some people-then you can go to your chief and/or dish out some consequences (you can punish bad behavior, they just have to know why in order for it to be effective). A truly military way of doing it would be to punish the group for the bad behavior of one and leave the group to fix things, but I wasn't a fan of it in basic training and don't feel like advocating it now (can't argue that it isn't effective though).

 

[ShyRem]

Y'all haven't run into those interns that are just so stinkin' clueless that even when folks explain to them in absolutely no uncertain very clear terms they are screwing up the interns STILL continue to be stupid? I'm talking arguing with ATTENDINGS and also doing exactly the opposite of what you were told to order. When faced with the insubordination, the intern said "I know better than you/them!!!"

Seriously. No kidding. And those type of interns (yes, they exist) get menial work that gets double-checked. It's extra work for everyone until they finally get canned. And then they appeal to get their spot back.

 

[dpmd]

We had a student once that was like that. I'm sure she is somewhere being a terrible intern right now (unless she didn't match which would be excellent for the world). We had one intern that also didn't respond well to being told he was f'ing up. Big problem was that he didn't respect women and didn't want them to tell him what to do. When half of those senior to him are women, plus female attendings, things can get annoying fast. What we did wrong there was not document enough details about his insubordination and his clinical shortcomings so all the program could do at the end was write a negative letter to his advanced program.

 

[gutonc]

We had a student once that was like that. I'm sure she is somewhere being a terrible intern right now (unless she didn't match which would be excellent for the world).

I had a med student when I was an intern who would write the following in her H+P. "Agree with excellent attending note. Admitted for X, Y and Z. Treatment plan per attending."

She got to spend some extra time on the IM service...mercifully it was after I was gone.

 

[dpmd]

This particular student was worse. She felt she knew more than those above her and would argue with them about patient care. She got fired from one rotation (a community hospital where there are few enough med students that the nurses think everyone is a doctor) because she told a nurse to stop a drip on an ICU patient and the nurse did it (I think the nurse got in trouble too, but I'm not sure). I think she either was about to or actually did pull a chest tube after being told the patient wasn't ready for that yet. It just goes to show that people really are too nice and try not to "torch someone's career" even when they probably deserve it.

 

[WingedOx]

First off, since she got a "competitive sub-specialty," this intern is probably better than her peers or even her resident, who has just one more year's experience.

Despite my original comment being moderated (for good reason, probably ), I still stand by my point. Not all of us with high board scores etc, choose to pick at eyeballs or skin lesions all day. I'm sure you're just an amazing pleasure to work with when called for a consult with that attitude.

 

[Ronin2258]

Personally, this person needs to have this attitude checked now, early in her career.

She is burning bridges with the attitude that can cost her referrals in her chosen specialty. Which one of you are going to trust your patients with someone like this, regardless of how good they are? The attitude will keep your patients from complying with treatment options they recommend.

Teamwork doesn't mean you work with the ones you chose. It means working with EVERYONE you get thrown in with on the team, and working with them for winning results (treating patients.) If this person fails to be a team worker, fails to be a positive contributor, they have, in my opinion, failed internship already.