PGY-2 and Job Is in Jeopardy (in the next few months)

[IonClaws]

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PGY-2 in Neurology here, just started about a month ago.
Basically, I had a meeting with 2 of the PGY-4s, one of whom was one of the 2 chiefs and my senior resident the last couple of weeks. She told me I was not doing well, and that there were many small things and a few big things that made things this way. The small things include being distracted on my phone during morning rounds (table and walking rounds) and not paying as much attention when the patients presented are not mine. People in Neuro have also noticed this and told me before. Sometimes, I'd either not hear something during rounds and have to clarify, or not put something updated in a copy-and-pasted note which the senior had to addend later.
Of the big things, one of them was missing big, potentially life-threatening issues in patients. For instance, there was a man I was seeing for stroke who had an event that looked sort of like a seizure but I wasn't sure. Instead of bringing it up to my senior immediately, I dismissed it as "not really a seizure" put it off until later...big mistake because he was in status later.
I also had issues before in 1st year of residency in IM with being inattentive and missing stuff, and I've already spoken with the PD about it and kept him updated on a monthly basis.
So, now I know some of the things I need to improve.
1. I'm going to turn my phone off during table and morning rounds because it's been repeatedly an issue and this seems to be the only way to fix it
2. I'm going to have a low threshold for potentially life threatening issues in patients and basically "know what I don't know."

I was told by my chief that if my performance does not significantly improve within the next few months that I'd probably lose my job. She stated she'd already spoken to the Program Director and another higher-up about it. Obviously, I want to avoid this and do everything I can to move past it and do well. They also brought up potential alternative career choices (like research) that I could get as an MD having passed Steps 1-3.

I'm really panicking and in a bit of a crisis here. Can anyone else offer more advice? Please?

Thank you. Wish me luck because I'll need it.

 

[calvnandhobbs68]

One, they're probably annoyed as hell that you can't seem to get your butt off your phone during rounds. Never have your phone on during rounds again. Turn your phone off and make it extremely clear you are listening to all the patient presentations. Ask thoughtful questions, suggest helpful workup or add to the differential for patients who are not yours...hell, ask if you can give the interns and med students a short presentation on a interesting case you saw that block. Do order readback for all the orders you put in. Ask your senior to go over a note with you every day or so if they have the time if you're finding they have had to modify your notes later.

If your problem before was with being inattentive and missing stuff, they're probably pissed that you've already been told about this and now you're playing on reddit during rounds, especially because it doesn't seem like your clinical acumen is making up for this. I'd be pissed too if you were playing on your phone/computer during rounds, copying forward notes with incorrect information and missing important clinical findings in patients. Why are you finding it so hard to pay attention? Do you not like neurology? Not like the service? Not like medicine? Have important amazon shopping you're trying to do? You need to be asking yourself these questions as to why you're finding it so hard to stay focused and attentive to your job.

 

[deleted480308]

Clearly you know the steps you need to take, I can't understand how you needed to hear that more than once but nonetheless

 

[Ludwig2000]

I’m sorry, but I’m very curious (like a cat (my friends call me Whiskers)) so can I ask what sorts of things you were doing on your phone during rounds?

 

[NotAProgDirector]

The good news is that you're already taking this seriously.

Reviewing your post history, this sounds identical to what happened in your IM PGY-1. You were overwhelmed at the beginning. By block 4 you were still requiring constant supervision by a resident. Likely your IM program would not have promoted you to the PGY-2 (this is a guess on my part based upon what you've written). You mentioned incorrect documentation in notes due to copy forward and lack of updating.

This is all very concerning, since these are skills you should have learned in your internship. It's only the second month of your PGY-2 -- if they are already warning you that your performance is poor enough that they may not continue your training, you are very far behind where they want you to be.

Thoughts:
1. Do not take your phone to work. At all. You've already built a reputation of being the guy/gal who spends too much time on their phone at work. You need to counter this, and the best solution is NO time on your phone.

2. Meet with your PD. Be proactive. Show them that you want to get better and you're taking this seriously.

3. Have you ever been evaluated for ADHD or some other learning problem? If not, consider it now.

4. You need an organizational system to keep track of all of the work of the day that needs to be done, and things that need to be reviewed by your seniors. You were supposed to gain this skill as an intern. If it's still a problem, you need to sort it out. You can see if someone can shadow you while you're pre-rounding and working, if possible.

5. If you're having trouble with note copy-paste, one trick is to copy the note and then select everything and apply some formatting -- change the color, make it italic, etc. Then, you review each part of the note and change it back one line or part at a time. That way, you can't miss something that needs to be updated. This is horribly inefficient -- you can't do this forever. But you can do it to learn how to review an entire note for accuracy.

 

[IonClaws]

The good news is that you're already taking this seriously.

Reviewing your post history, this sounds identical to what happened in your IM PGY-1. You were overwhelmed at the beginning. By block 4 you were still requiring constant supervision by a resident. Likely your IM program would not have promoted you to the PGY-2 (this is a guess on my part based upon what you've written). You mentioned incorrect documentation in notes due to copy forward and lack of updating.

This is all very concerning, since these are skills you should have learned in your internship. It's only the second month of your PGY-2 -- if they are already warning you that your performance is poor enough that they may not continue your training, you are very far behind where they want you to be.

Thoughts:
1. Do not take your phone to work. At all. You've already built a reputation of being the guy/gal who spends too much time on their phone at work. You need to counter this, and the best solution is NO time on your phone.

2. Meet with your PD. Be proactive. Show them that you want to get better and you're taking this seriously.

3. Have you ever been evaluated for ADHD or some other learning problem? If not, consider it now.

4. You need an organizational system to keep track of all of the work of the day that needs to be done, and things that need to be reviewed by your seniors. You were supposed to gain this skill as an intern. If it's still a problem, you need to sort it out. You can see if someone can shadow you while you're pre-rounding and working, if possible.

5. If you're having trouble with note copy-paste, one trick is to copy the note and then select everything and apply some formatting -- change the color, make it italic, etc. Then, you review each part of the note and change it back one line or part at a time. That way, you can't miss something that needs to be updated. This is horribly inefficient -- you can't do this forever. But you can do it to learn how to review an entire note for accuracy.

Thanks for all of your advice.
For the bolded question, yes, I was actually diagnosed as a youngster, 7 years of age. Re-diagnosed in medical school. Unfortunately I am not able to take stimulant medications because I also have epilepsy.

 

[calvnandhobbs68]

Thanks for all of your advice.
For the bolded question, yes, I was actually diagnosed as a youngster, 7 years of age. Re-diagnosed in medical school. Unfortunately I am not able to take stimulant medications because I also have epilepsy.

Why?

That's not an absolute contraindication unless you actually had increased seizures with a certain class of stimulants and even then you could try the other class. Most recent research shows that there's no increased risk of seizures with stimulants. And if it means being kicked out of residency or not because you can't focus, I'd suggest getting in to see psychiatry ASAP.

 

[emergentmd]

In all seriousness, why does an adult person who is smart enough to get into/pass medical school have to be told not to be on your phone during work????

I get making mistakes. I get not taking issues seriously due to ignorance. I get making charting mistakes. But having to be told not to use your phone while dealing with patients or during active patient care is ridiculous.

I have been in medicine seeing patients for 25 years and for most of it having my cell phone in my pocket. I can't remember ONE time that I stopped during dealing with patients to look at my phone no matter what. I ALWAYS put it on buzz/mute bc its extremely disrespectful to have it go off when talking to a patient.

 

[thenerveofu]

You should take this extremely seriously. Sounds like you were fortunate to survive intern year despite prior similar issues. You have to stop and realize that residency is medical training. Think about it.. it's not sitting in the back of a class and playing on your phone/laptop while the teacher/professor is talking. It's a paying job.. in a hospital.. with sick patients.. and serious physicians.. who are looking at new interns/residents with a microscope because they don't want you harming their patients and at the same time trying to teach you how to truly be a doctor. In med school you can be really smart, pass tests, show up for rounds, present your few pts and kinda get by. Not that it's easy but it's not as hard as residency.... especially a Neurology residency.

Residency is a whole new ball game. It's a big level up from med school and it requires your absolute best effort at all times. Coming into neuro residency you should have been one of the best IM interns honestly. It requires a strong base of medical knowledge. As a new neuro resident you should be focused on:

1) Know everything about your patients
2) Know everything about ALL the patients on your census
3) Read 2-3 hrs everyday. Blumenfeld neuroanatomy and Bradley or Merritt's is a good start in PGY-2.
4) Read up on your patients illnesses or research the clinical question for the decision making on rounds
5) Tell your senior everything.. i dont care if they had a eyelid twitch. Don't brush anything off bc you don't know what you don't know.
6) Mistakes in hospitals cost ppl their lives. Try to avoid as best you can.
7) Say goodbye to your cellphone. Don't get in trouble bc you can't keep eyes off your phone.
8) Understand you are always under the microscope. It doesn't take long to build a bad reputation. It takes longer to develop a good rep but ppl talk and they will know the good seeds from the bad ones.
9) Be nice to the nurses, they will look out for you
10) Avoid doing copy-paste on your notes for some time. Although it's common practice it becomes a big issue when ppl make mistakes.. pt who is back on the floor after transferred from ICU yesterday, has a prog note that describes him as intubated, sedated. Read every single letter in your note before you submit it.
11) Apologize and let them know you will do better. It's still early so hopefully they give you a chance but you will need to do a complete 180 in a short period of time. Don't ever let them say you didn't try hard or didn't work hard or was too distracted or didn't pay attention to detail or failed to communicate/act should be your new goals.

 

[Crayola227]

They already brought up other career choices? Mostly non-clinical? Ouch.

This looks really bad.

Here's the thing. Because the meetings, at least at first, talk about how to save your job, residents think it's not too late. Thing is, the path to firing a resident MUST include such talk. It's part of paving the path.

You still need to follow all the advice you can to try to be the best resident possible. Whether or not you can save your job, it will still help you, believe me.

I would bring up your diagnosis to your program and seek psych care ASAP. I would start instituting all the non-med management tips out there that exist for ADHD.

Agree, trash the phone.

Somewhere I discuss my own system of not losing track of to-dos and being more efficient with notes. I had to be because I was a scattered sort of resident too.

I've been told by more than one PD/Chief, the most important things are your work ethic and character. So a big one is no lying. The other thing, people are helping you address here.

 

[Mass Effect]

PGY-2 in Neurology here, just started about a month ago.
Basically, I had a meeting with 2 of the PGY-4s, one of whom was one of the 2 chiefs and my senior resident the last couple of weeks. She told me I was not doing well, and that there were many small things and a few big things that made things this way. The small things include being distracted on my phone during morning rounds (table and walking rounds) and not paying as much attention when the patients presented are not mine. People in Neuro have also noticed this and told me before. Sometimes, I'd either not hear something during rounds and have to clarify, or not put something updated in a copy-and-pasted note which the senior had to addend later.
Of the big things, one of them was missing big, potentially life-threatening issues in patients. For instance, there was a man I was seeing for stroke who had an event that looked sort of like a seizure but I wasn't sure. Instead of bringing it up to my senior immediately, I dismissed it as "not really a seizure" put it off until later...big mistake because he was in status later.
I also had issues before in 1st year of residency in IM with being inattentive and missing stuff, and I've already spoken with the PD about it and kept him updated on a monthly basis.
So, now I know some of the things I need to improve.
1. I'm going to turn my phone off during table and morning rounds because it's been repeatedly an issue and this seems to be the only way to fix it
2. I'm going to have a low threshold for potentially life threatening issues in patients and basically "know what I don't know."

I was told by my chief that if my performance does not significantly improve within the next few months that I'd probably lose my job. She stated she'd already spoken to the Program Director and another higher-up about it. Obviously, I want to avoid this and do everything I can to move past it and do well. They also brought up potential alternative career choices (like research) that I could get as an MD having passed Steps 1-3.

I'm really panicking and in a bit of a crisis here. Can anyone else offer more advice? Please?

Thank you. Wish me luck because I'll need it.

Thanks for all of your advice.
For the bolded question, yes, I was actually diagnosed as a youngster, 7 years of age. Re-diagnosed in medical school. Unfortunately I am not able to take stimulant medications because I also have epilepsy.

Wishing you luck! I also want to say that despite some of the criticism you've received here, I applaud you for telling the truth in this post as opposed to some of the posts we read where people pretend they had no shortcomings. Your post shows some insight. Now you have to address the issues. I would follow aProgramDirector's advice to the letter.

Also, if you're concerned about stimulants for your ADHD, try non-stimulants and see if that helps.

Good luck to you! Hope you get this under control!

 

[Piebaldi]

PGY-2 in Neurology here, just started about a month ago.
Basically, I had a meeting with 2 of the PGY-4s, one of whom was one of the 2 chiefs and my senior resident the last couple of weeks. She told me I was not doing well, and that there were many small things and a few big things that made things this way. The small things include being distracted on my phone during morning rounds (table and walking rounds) and not paying as much attention when the patients presented are not mine. People in Neuro have also noticed this and told me before. Sometimes, I'd either not hear something during rounds and have to clarify, or not put something updated in a copy-and-pasted note which the senior had to addend later.
Of the big things, one of them was missing big, potentially life-threatening issues in patients. For instance, there was a man I was seeing for stroke who had an event that looked sort of like a seizure but I wasn't sure. Instead of bringing it up to my senior immediately, I dismissed it as "not really a seizure" put it off until later...big mistake because he was in status later.
I also had issues before in 1st year of residency in IM with being inattentive and missing stuff, and I've already spoken with the PD about it and kept him updated on a monthly basis.
So, now I know some of the things I need to improve.
1. I'm going to turn my phone off during table and morning rounds because it's been repeatedly an issue and this seems to be the only way to fix it
2. I'm going to have a low threshold for potentially life threatening issues in patients and basically "know what I don't know."

I was told by my chief that if my performance does not significantly improve within the next few months that I'd probably lose my job. She stated she'd already spoken to the Program Director and another higher-up about it. Obviously, I want to avoid this and do everything I can to move past it and do well. They also brought up potential alternative career choices (like research) that I could get as an MD having passed Steps 1-3.

I'm really panicking and in a bit of a crisis here. Can anyone else offer more advice? Please?

Thank you. Wish me luck because I'll need it.

Perhaps you have attention issues? Like others have said, you should get tested for ADHD.
It seems that you know what you must do, so do it.

One thing that you wrote in your post which in general bothers me when other residents, including chiefs do, is supposedly talk about whether other residents will keep/not keep their jobs, talking to the PD about other residents' performance, etc.

No resident has that power. Not even chiefs. Chiefs are still residents. No one resident wise in my program had any power of that kind, other than the PD. So that a jerk maneuver for a resident, again even a chief to say oh I talked to the PD about your performance. Sure they are chiefs and all, but they have no authority to do something like that.

It's a power trip and it's a massive pet peeve for me. Although like aPD said I. believe, you should be proactive and talk to the PD. Tell him/her about ways you are working on improving, get frequent feedback, know your patients well, ask questions frequently, try to read as much as you can, be involved.

Are you are bored to tears because of the specialty? Is it not a good match?

 

[rokshana]

Perhaps you have attention issues? Like others have said, you should get tested for ADHD.
It seems that you know what you must do, so do it.

One thing that you wrote in your post which in general bothers me when other residents, including chiefs do, is supposedly talk about whether other residents will keep/not keep their jobs, talking to the PD about other residents' performance, etc.

No resident has that power. Not even chiefs. Chiefs are still residents. No one resident wise in my program had any power of that kind, other than the PD. So that a jerk maneuver for a resident, again even a chief to say oh I talked to the PD about your performance. Sure they are chiefs and all, but they have no authority to do something like that.

It's a power trip and it's a massive pet peeve for me. Although like aPD said I. believe, you should be proactive and talk to the PD. Tell him/her about ways you are working on improving, get frequent feedback, know your patients well, ask questions frequently, try to read as much as you can, be involved.

Are you are bored to tears because of the specialty? Is it not a good match?

Places are different about that...we had 369 evaluations and as a senior resident, you were asked about your interns performance and if there are any issues that need to be addressed...the PD, aPDs and even the attendings don’t see the the details.

Hopefully the chiefs are trying to help
This guy before the issues work their way up to the PD...and they maybe warning him as opposed to threatening him...it very well could be that at their program issues like his have gotten people terminated.

Understandably if a co intern or a co resident sees something that is of true concern for patient or resident safety ( not something just through the grapevine), they would go to their chief and say something...though i would hope they would come to the resident with their concerns first.

 

[Piebaldi]

Places are different about that...we had 369 evaluations and as a senior resident, you were asked about your interns performance and if there are any issues that need to be addressed...the PD, aPDs and even the attendings don’t see the the details.

Hopefully the chiefs are trying to help
This guy before the issues work their way up to the PD...and they maybe warning him as opposed to threatening him...it very well could be that at their program issues like his have gotten people terminated.

Understandably if a co intern or a co resident sees something that is of true concern for patient or resident safety ( not something just through the grapevine), they would go to their chief and say something...though i would hope they would come to the resident with their concerns first.

It probably does vary. At my program, I had to make a complain about a junior resident that went off the deep end and went on a rampage of verbal abuse towards me. The PD didn't seem to care. This was a resident who also had failed a year of med school, and was just overall not a good resident. However interestingly enough when junior residents made complaints they were taken seriously.

 

[Mass Effect]

Perhaps you have attention issues? Like others have said, you should get tested for ADHD.
It seems that you know what you must do, so do it.

One thing that you wrote in your post which in general bothers me when other residents, including chiefs do, is supposedly talk about whether other residents will keep/not keep their jobs, talking to the PD about other residents' performance, etc.

No resident has that power. Not even chiefs. Chiefs are still residents. No one resident wise in my program had any power of that kind, other than the PD. So that a jerk maneuver for a resident, again even a chief to say oh I talked to the PD about your performance. Sure they are chiefs and all, but they have no authority to do something like that.

What?? I would be hesitant to make such sweeping generalizations. There are many institutions (including mine) where chiefs are expected to bring any performance issues to the PD sooner rather than later. The chiefs are the people in the prime position to know if someone is struggling and often, attendings come to the chiefs expecting information that needs to be conveyed to the PD will be conveyed. Not sure how it worked at your place, but that sounds like the exception, not the rule, based on my experience as chief as well as my communication with other chiefs at programs across the country.

It's a power trip and it's a massive pet peeve for me.

See above. Calling a legitimate role of the job a "power trip" won't end well for the resident in question.

It probably does vary. At my program, I had to make a complain about a junior resident that went off the deep end and went on a rampage of verbal abuse towards me. The PD didn't seem to care.

Again, your experience and that speaks more to your PD and his/her relationship with you, imo. Don't assume that's what always happens.

 

[Piebaldi]

What?? I would be hesitant to make such sweeping generalizations. There are many institutions (including mine) where chiefs are expected to bring any performance issues to the PD sooner rather than later. The chiefs are the people in the prime position to know if someone is struggling and often, attendings come to the chiefs expecting information that needs to be conveyed to the PD will be conveyed. Not sure how it worked at your place, but that sounds like the exception, not the rule, based on my experience as chief as well as my communication with other chiefs at programs across the country.



See above. Calling a legitimate role of the job a "power trip" won't end well for the resident in question.



Again, your experience and that speaks more to your PD and his/her relationship with you, imo. Don't assume that's what always happens.

Well i respectfully disagree. A resident chief or not is still a resident. Having a resident determine supposedly what the academic future a different resident will have is nutso. Not to mention that a lot of resident pettiness is not infrequent. That's my expeirence. You don't have to agree.

 

[Mass Effect]

Well i respectfully disagree. A resident chief or not is still a resident. Having a resident determine supposedly what the academic future a different resident will have is nutso. Not to mention that a lot of resident pettiness is not infrequent. That's my expeirence. You don't have to agree.

Who said anything about a chief deciding what the academic future of another resident is? Just as a senior resident is expected to teach and mentor junior residents and therefore, know if there are performance issues, so do chiefs, either because they see it themselves or because junior residents, attendings, or other chiefs come to him/her. The chief goes to the PD. It's the PD who decides what happens, after he/she looks into it, not the chief. The chief makes no decisions; they just report to the PD.

But in a lot of programs (and it sounds like the one the OP is in) the chief is privy to what happens with remediation because sometimes, the chief is oversees remediation or is in contact with the chief handling remediation if it's off-service. For example, in psych, our interns rotate on medicine for 6 months. The medicine chiefs let us (psych chiefs) know if there is an issue. We'd take it to the PD. The PD may touch base with the medicine PD, but the IM chiefs were the ones who further evaluated performance of our interns, not the IM PD.

 

[rokshana]

Well i respectfully disagree. A resident chief or not is still a resident. Having a resident determine supposedly what the academic future a different resident will have is nutso. Not to mention that a lot of resident pettiness is not infrequent. That's my expeirence. You don't have to agree.

Actually they are not...at least in internal medicine and pediatrics...they have graduated and in many places are junior attendings.

 

[Piebaldi]

Actually they are not...at least in internal medicine and pediatrics...they have graduated and in many places are junior attendings.

Perhaps in those fields, that may apply. In other fields it does not. In our field certainly they are just residents, not attendings.

 

[Crayola227]

Doesn't matter. In order to even become a chief, that person has to have the administration behind them to be chosen. They are specifically chosen for the job of being in charge of the residents on a number of fronts. That doesn't mean they get final say on terminating a resident.

However, at least where I was, the chiefs were basically chosen to be the "bad cop" while the PDs and higher ups played "good cop" on a lot of issues. Don't ever assume that the chiefs don't have authority over you or aren't acting entirely at the behest of the program admin, even if the rest of the admin seems to "love" you while it seems it's just the chiefs that "hate" you. You could be woefully ignorant on the politics and how the admin assigns these roles and what their agenda is.

If you don't think whatever they say/think/write down on paper doesn't get used in a building a case to terminate you, whether that's factored in at a one-on-one or round table meeting, or more formally put to paper, then you have no idea how these things work. Doesn't mean they get the say to put you in the coffin, but the chief can certainly be one of the bigger nails.

(Hint, if they're going to terminate you, you better believe every rotten thing anyone ever said about you, from the MS3 to the janitor to certainly the chief, will be included in that paperwork trail they're building.) That kind of a file can follow you around forever.

The admin can choose to ignore whatever the chiefs say, sure, or they can use it to destroy you. I can't say how much a chief in your corner can help you. When you're the problem resident you need every friend you can get, and then some.

Your mission, should you choose to accept it, is to give them as little ammo as possible. Especially because even if you can't keep them from firing you, you have just a little control over how that file reads.

Hell, maybe they just wanted to test your response to the idea of being terminated. That could be a little cruel if you're already crapping your pants, but it seems like a lot of residents in trouble don't know how much trouble they're in, and where things can go. Too often we can make residents feel like they're "fire-proof." So they could really be doing you a big favor putting this on your radar, whether it's a scare tactic or they've been to the early meetings.

The only way to save yourself is to improve, demonstrate character and work ethic, and get as many human beings around you to think you stand out in those things and likeability. Don't minimize the role of the chief. Assume they have a lot of power and the inside track, and kow tow.

People hate chiefs (I could write paragraphs on how this is an effective division of labor for a program) and so they hate chiefs flexing. Sometimes the chief is the only one that gave you the heads up you were going to get your ass canned. I support the delivery of the message.

 

[Apollyon]

That "like" is for the "Mission: Impossible" reference.

 

[Mass Effect]

Doesn't matter. In order to even become a chief, that person has to have the administration behind them to be chosen. They are specifically chosen for the job of being in charge of the residents on a number of fronts. That doesn't mean they get final say on terminating a resident.

However, at least where I was, the chiefs were basically chosen to be the "bad cop" while the PDs and higher ups played "good cop" on a lot of issues. Don't ever assume that the chiefs don't have authority over you or aren't acting entirely at the behest of the program admin, even if the rest of the admin seems to "love" you while it seems it's just the chiefs that "hate" you. You could be woefully ignorant on the politics and how the admin assigns these roles and what their agenda is.

If you don't think whatever they say/think/write down on paper doesn't get used in a building a case to terminate you, whether that's factored in at a one-on-one or round table meeting, or more formally put to paper, then you have no idea how these things work. Doesn't mean they get the say to put you in the coffin, but the chief can certainly be one of the bigger nails.

(Hint, if they're going to terminate you, you better believe every rotten thing anyone ever said about you, from the MS3 to the janitor to certainly the chief, will be included in that paperwork trail they're building.) That kind of a file can follow you around forever.

The admin can choose to ignore whatever the chiefs say, sure, or they can use it to destroy you. I can't say how much a chief in your corner can help you. When you're the problem resident you need every friend you can get, and then some.

Your mission, should you choose to accept it, is to give them as little ammo as possible. Especially because even if you can't keep them from firing you, you have just a little control over how that file reads.

Hell, maybe they just wanted to test your response to the idea of being terminated. That could be a little cruel if you're already crapping your pants, but it seems like a lot of residents in trouble don't know how much trouble they're in, and where things can go. Too often we can make residents feel like they're "fire-proof." So they could really be doing you a big favor putting this on your radar, whether it's a scare tactic or they've been to the early meetings.

The only way to save yourself is to improve, demonstrate character and work ethic, and get as many human beings around you to think you stand out in those things and likeability. Don't minimize the role of the chief. Assume they have a lot of power and the inside track, and kow tow.

People hate chiefs (I could write paragraphs on how this is an effective division of labor for a program) and so they hate chiefs flexing. Sometimes the chief is the only one that gave you the heads up you were going to get your ass canned. I support the delivery of the message.

I agree with most of this, though I wouldn't make it sound like chiefs are out to get you. At least speaking for me personally, I was always on the side of the resident and 99% of the residents knew that, I think. At my program, chiefs had very little actual "power," but resident progress was conveyed to the PD as were other things that popped up. It was then up to the PD to determine what to do with that information. And yes, there were two times that I told a resident they were in a lot of trouble (not by me, but by the PD). In one case, the resident was in a world of trouble and I don't think she realized how much was happening behind the scenes. But that's the kind of thing that residents who are inclined to blame others would lash out about and believe the chief is on a power trip, as @Piebaldi suggested. Being chief is tough and there should be no room for chiefs who try to get others in trouble, but there should also not be residents who believe that chiefs are evil, vindictive folks who are petty and power hungry.

 

[rokshana]

Perhaps in those fields, that may apply. In other fields it does not. In our field certainly they are just residents, not attendings.

It’s not a “perhaps”...IM and peds are graduated residents that stay for an extra year...the only exception are small programs , less than 10 residents , where there can be a 3rd year chief.

 

[rokshana]

Perhaps in those fields, that may apply. In other fields it does not. In our field certainly they are just residents, not attendings.

I didn’t realize you are neurology...thought you were doing a pain fellowship

 

[DarkHorizon]

Chiefs don’t really have any power to outright get someone fired but they can make your life miserable. I was a chief (everyone is a chief in surgery) and OPs behavior would have been nipped in the bud. Me and the other chiefs would have come down on him hard right away if we saw him on the phone. This was the model at our residency. Chiefs were there to take responsibility of the whole service and managed these issues, we usually shielded junior residents from any higher up scrutiny and took the fall. In turn, juniors worked hard and followed directions.

In my experience at least, we never had issues because no one wanted to let the team down. Realize this might be different in other fields, but that is how it usually is in surgery.

 

[Piebaldi]

I didn’t realize you are neurology...thought you were doing a pain fellowship

I will do a pain fellowship you are correct. I am not Neuro, I am PM&R. Our chiefs are residents not attendings.

 

[Kakoy]

Chiefs don’t really have any power to outright get someone fired but they can make your life miserable. I was a chief (everyone is a chief in surgery) and OPs behavior would have been nipped in the bud. Me and the other chiefs would have come down on him hard right away if we saw him on the phone. This was the model at our residency. Chiefs were there to take responsibility of the whole service and managed these issues, we usually shielded junior residents from any higher up scrutiny and took the fall. In turn, juniors worked hard and followed directions.

In my experience at least, we never had issues because no one wanted to let the team down. Realize this might be different in other fields, but that is how it usually is in surgery.

I was chief in Medicine subspecialty and operate similarly! If I see fixable/unprofessional behavior, I will talk to you and give you a heads up before any attending notice. That way, the fellow have time to fix it before it ruin their reputation in the attending's eyes. Then again, I tried to be a benign chief! Hated the job! So glad it's over!

 

[Dral]

They already brought up other career choices? Mostly non-clinical? Ouch.

This looks really bad.

Agree. That is basically the backswing of the hammer that is going to hit the proverbial nail in the coffin.

I can't say for sure, but based on what I've seen (not directed at me personally) they are basically telling you "I'm not sure I would trust a friend or loved one in your care. Maybe you're better off in a career where you are not taking care of people in a clinical setting".

The only time you should be on your phone at work is when the attending or an upper level asks you to look up some obscure thing related to a patient. We had a COW with us during intern year for that though anyway.

I like the advice of just not having your phone (unless it's used as a pager, tiger text, etc).

Try to see how your colleagues are taking care of their patients to see where the balance is. You need to try to strike a balance of being obsessive (Hmm, I'm not sure this is a seizure, I don't think it is, but there is a small chance it could be...I must address this now) and not being TOO obsessive (This patient just twitched a little and scratched their face, maybe it's a seizure). As long as you strike the correct balance nobody should give you a hassle. Your current modus operandi should be to be super cautious while you're learning. Later (like later as an attending) after years of experience, you can start to make the hairline clinical judgments. The fact that you are in essence doing that your first year of specialty training is likely why you are under scrutiny (at least in part).

Good luck.

 

[evilbooyaa]

Good news is that you have insight.
Bad news is that this is the second time you're hearing of at least two of these issues (being distracted on your phone, making visible mistakes with charting).

1) Phone stays in pocket/locker/home as long as you are on the clock. Hopefully you have a pager and they don't force you to use your personal phone for stuff like this.

2) Copy forward is no longer an option for you. Write it from scratch (or a template that pulls recent vitals and stuff) every time.

3) The mistake about not reporting a seizure is, to me, the smallest infraction. Yes, you should have told your sernior, and yes you should have a lower threshold now than you did previously to run things up the ladder, but that's a true medical error, not something that comes off as laziness or carelessness (like points 1 and 2).

 

[CidHighwind]

If students get in trouble with phones, I’m sure residents do as well. You could have at least occasionally looked stuff up on UpToDate during rounds and say it so they’d at least kind of think you were just reading up on stuff. I guess it’s bettet that the chief told you this and not the PD, since it means it’s not an official remediation/probation. IDK, I feel like they feel like your behavior is that of a marginal medical student, since you’re describing things that I would be reprimanded for.

 

[ryerica22]

Why?

That's not an absolute contraindication unless you actually had increased seizures with a certain class of stimulants and even then you could try the other class. Most recent research shows that there's no increased risk of seizures with stimulants. And if it means being kicked out of residency or not because you can't focus, I'd suggest getting in to see psychiatry ASAP.

I have had pts with seizures get more frequent seizures because of stimulants. Please don't give the OP advice about stimulants. OP, you need to see a Neurologist if you have Epilepsy maybe that is causing you issues with being distracted?

 

[calvnandhobbs68]

I have had pts with seizures get more frequent seizures because of stimulants. Please don't give the OP advice about stimulants. OP, you need to see a Neurologist if you have Epilepsy maybe that is causing you issues with being distracted?

Thanks for your anecdotes bro try looking at the actual literature. Reminds me of my one attending who had a patient get a rash with Bactrim and never gave anyone bactrim again for the next year.

NEJM Journal Watch: Summaries of and commentary on original medical and scientific articles from key medical journals

NEJM Journal Watch reviews over 250 scientific and medical journals to present important clinical research findings and insightful commentary

www.jwatch.org

Sorry also forgot the part where I advised OP to start writing himself scripts for stimulants.

 

[hallowmann]

Thanks for your anecdotes bro try looking at the actual literature. Reminds me of my one attending who had a patient get a rash with Bactrim and never gave anyone bactrim again for the next year.

NEJM Journal Watch: Summaries of and commentary on original medical and scientific articles from key medical journals

NEJM Journal Watch reviews over 250 scientific and medical journals to present important clinical research findings and insightful commentary

www.jwatch.org

Sorry also forgot the part where I advised OP to start writing himself scripts for stimulants.

There's lots of reasons not to prescribe people Bactrim if you can avoid it though. After seeing a couple episodes of Bactrim induced acute hepatitis and SJS (and with TEN at that) after a course of Bactrim, I can't say I'm not hesitant when I prescribe it. Admitting someone to the hospital because their skin is sloughing off is pretty rough, especially when they could have just gotten Keflex or Macrobid.

Agree with your statement about seizures and stimulants though.

 

[thepoopologist]

Thank you. Wish me luck because I'll need it.

My 2 cents, I don't think the phone would've been an issue if you weren't missing things clinically.

You know what you need to do. Find the motivation to swallow your pride and change. The person they see now should be vastly different than the person they saw before.

 

[neoexile]

Can I have your job?

No. Go crawl back to your cave

 

[2021islookingbetter]

The good news is that you're already taking this seriously.

Reviewing your post history, this sounds identical to what happened in your IM PGY-1. You were overwhelmed at the beginning. By block 4 you were still requiring constant supervision by a resident. Likely your IM program would not have promoted you to the PGY-2 (this is a guess on my part based upon what you've written). You mentioned incorrect documentation in notes due to copy forward and lack of updating.

This is all very concerning, since these are skills you should have learned in your internship. It's only the second month of your PGY-2 -- if they are already warning you that your performance is poor enough that they may not continue your training, you are very far behind where they want you to be.

Thoughts:
1. Do not take your phone to work. At all. You've already built a reputation of being the guy/gal who spends too much time on their phone at work. You need to counter this, and the best solution is NO time on your phone.

2. Meet with your PD. Be proactive. Show them that you want to get better and you're taking this seriously.

3. Have you ever been evaluated for ADHD or some other learning problem? If not, consider it now.

4. You need an organizational system to keep track of all of the work of the day that needs to be done, and things that need to be reviewed by your seniors. You were supposed to gain this skill as an intern. If it's still a problem, you need to sort it out. You can see if someone can shadow you while you're pre-rounding and working, if possible.

5. If you're having trouble with note copy-paste, one trick is to copy the note and then select everything and apply some formatting -- change the color, make it italic, etc. Then, you review each part of the note and change it back one line or part at a time. That way, you can't miss something that needs to be updated. This is horribly inefficient -- you can't do this forever. But you can do it to learn how to review an entire note for accuracy.

-I am going to guess that you have a hard time remembering things to complete throughout the day, difficulty completing notes quickly/ efficiently, difficulty presenting patients during rounds, feel overloaded a bit quicker than the other residents.
-First off, know you are not alone on this and also that it has no relation to how smart you are as an individual. What you are describing are executive function difficulties.
-Be honest with your PD and adviser. Agree with aPD: Consider additional testing for confirmation/ documentation and document that you advised them of this in the form of an e-mail either before or after meeting with them. If you request a meeting they will see it as you taking initiative and could save you a lot of hassle.
-minimize phone use to only required medical things. Not having your phone with you is unrealistic IMO.
-seek out and initiate the process that your program has for disability assistance services. Residency in America is not conducive to most of the accommodations that would help with ADHD, but start the process anyways as it will allow you more options that will lead you to completing residency. Yes, this is also for legal reasons.

- Think about it this way: If you continue to have difficulty, what would you write on a personal statement that you did to address the issues while still a resident?
Also of note: regardless of what field you go into, this may be a problem in all of them as a resident and as an attending. Main thing is to develop good compensatory strategies right now.

 

[Mass Effect]

Based on what you are describing, this sounds like ADHD-Predominately Inattentive (PI) type.
-I am going to guess that you have a hard time remembering things to complete throughout the day, difficulty completing notes quickly/ efficiently, difficulty presenting patients during rounds, feel overloaded a bit quicker than the other residents.
-First off, know you are not alone on this and also that it has no relation to how smart you are as an individual. What you are describing are executive function difficulties.
-Be honest with your PD and adviser. Agree with aPD: Consider additional testing for confirmation/ documentation and document that you advised them of this in the form of an e-mail either before or after meeting with them. If you request a meeting they will see it as you taking initiative and could save you a lot of hassle.
-minimize phone use to only required medical things. Not having your phone with you is unrealistic IMO.
-If you have ADHD-PI: seriously, seriously consider printing out the wikipedia page (best source I have found) and showing that to your seniors, adviser, PD so they understand what is hard for you, why it is hard, and how to help.
-seek out and initiate the process that your program has for disability assistance services. Residency in America is not conducive to most of the accommodations that would help with ADHD, but start the process anyways as it will allow you more options that will lead you to completing residency. Yes, this is also for legal reasons.

- Think about it this way: If you continue to have difficulty, what would you write on a personal statement that you did to address the issues while still a resident?
Also of note: regardless of what field you go into, this may be a problem in all of them as a resident and as an attending. Main thing is to develop good compensatory strategies right now.
-Podcast: Attention Talk Radio- fantastic resource with advice that might help.
-Maybe short term zinc supplementation (???- dunno how that would affect seizure threshold).

PM me if you have any specific questions.

Attention deficit hyperactivity disorder predominantly inattentive - Wikipedia

en.wikipedia.org

I disagree with this. I would never diagnose on the Internet, but as a psychiatrist, the description of the above can't all be attributed to ADHD (even though there seems to be a movement in America to blame every single thing on ADHD). For instance, the OP not getting help when needing help and instead brushing it off and minimizing symptoms isn't really ADHD. One could make an argument that playing on his phone during rounds is ADHD, but even that I would say is just unprofessionalism. Printing out a Wiki page to show to seniors on his behalf isn't going to work. Self-diagnosis under these circumstances will make it seem the OP is trying to excuse poor behavior, even if that's not the case. If the OP wants to be evaluated for ADHD, he needs to see a psychiatrist and have a thorough evaluation along with recommendations for success at work. That's what you share, if anything, not a Wiki page along with paperwork from the disability office.

 

[hamstergang]

Based on what you are describing, this sounds like ADHD-Predominately Inattentive (PI) type.
...
-Maybe short term zinc supplementation (???- dunno how that would affect seizure threshold).

I don't think it's a good idea to be making diagnoses and treatment recommendations over the internet.

-If you have ADHD-PI: seriously, seriously consider printing out the wikipedia page (best source I have found) and showing that to your seniors, adviser, PD so they understand what is hard for you, why it is hard, and how to help.

Do not ever print out Wiki articles on medical issues and give them to doctors, especially those more senior than you.

 

[Apollyon]

I am gratified that our psychiatrist friends are sounding off, correctly, about not diagnosing someone's pathology online.

For others who may not know, look up Barry Goldwater, in the 1964 election.

 

[Bernardo_11]

I am gratified that our psychiatrist friends are sounding off, correctly, about not diagnosing someone's pathology online.

For others who may not know, look up Barry Goldwater, in the 1964 election.

I remember hearing about that years ago. Had to look it up though for review. My source ironically was wikipedia 😀

 

[evilbooyaa]

Medical advice

Jesus man, have you never heard about diagnosing somebody you've never met, especially not on the internet? This is so incredibly stupid.

 

[2021islookingbetter]

I disagree with this. I would never diagnose on the Internet, but as a psychiatrist, the description of the above can't all be attributed to ADHD (even though there seems to be a movement in America to blame every single thing on ADHD). For instance, the OP not getting help when needing help and instead brushing it off and minimizing symptoms isn't really ADHD. One could make an argument that playing on his phone during rounds is ADHD, but even that I would say is just unprofessionalism. Printing out a Wiki page to show to seniors on his behalf isn't going to work. Self-diagnosis under these circumstances will make it seem the OP is trying to excuse poor behavior, even if that's not the case. If the OP wants to be evaluated for ADHD, he needs to see a psychiatrist and have a thorough evaluation along with recommendations for success at work. That's what you share, if anything, not a Wiki page along with paperwork from the disability office.

Agreed. It was my mistake for offering any medical advice and I retract that statement. I will point out that the OP stated they have been formally diagnosed with ADHD (twice) and that I agreed with previous comments about considering formal testing for a complete diagnosis. I completely understand the hating of wikipedia as a trusted source of primary medical knowledge, but it can be a good tool for summary information when used with fact-checking. I will assume we all have our own personal favorite resources for the primary literature.

Speaking generally for any medical professional diagnosed with ADHD who thinks their condition is significantly affecting their ability to function in the workplace: it is important to know that ADA protections only come into effect when the employer is made aware of the potential of a medical cause for those difficulties even if awaiting formal testing. If you "lose your job" before disclosing a real or potential disability, it is unlikely you be able to make a case for disability discrimination.

 

[xoggyux]

To the OP. I think your understanding of this problem is a fantastic first step towards addressing them and hopefully fixing them in a prompt and satisfactory way. The most common reaction of most people in your situation is to blame everyone else and dismiss them as rude, racist, sexist, etc and overblowing problems out of proportion. You were sincere in recognizing your shortcomings I think the odds are in your favor that you can and will overcome this if you put some effort on your part. I want to give you credit for this.

Whether or not you have a medical condition that requires attention or not just excuses it with your doctor but certainly, there are many things from the behavioral point of view that you can, and should address.
You mention the obvious one (DON'T TOUCH THE FIGGING PHONE!) and discuss every aspect of the patient's care with your team no matter how insignificant they may originally seem. Sometimes this can be hard to do without appearing to be the "messenger" between the nurse and the other senior residents or attending but that's the wrong way to look at it. What you should do is to make sure everyone is on the same page.

Finally, be aware that now you will feel that everything you do will be scrutinized and reviewed under a microscope and you will be paranoic because everyone is looking after your tail. The reality is that they will, you already drew a big red target on your back and people are aiming at it. I am telling you this because you will perceive this regardless of whether I tell you or not and you might end up making even more mistakes (and people find more mistakes that are trivial and would otherwise go unnoticed if any other resident did it instead of you). Just be careful and not scared. Scared people make bigger and more frequent mistakes, careful people still make mistake but they are in a better position to recognize them earlier and addressing them appropriately. Keep head cool. Never contradict any senior resident/attending feedback even when you feel it is unwarranted or unfair. If there is a misunderstanding, take the feedback and later, if you have proof, GENTLY and CAREFULLY clear it out with the appropriate person in private if need to. Keep confrontation to the minimum without allowing abuse (and abuse, in this case, is a bit fluid, you might have to take a bit of abuse for a while =))

If it won't affect your performance, be the first one to volunteer to take the new patient, the new consult or to cover for your teammates should they become sick or need time off or to give a lecture to medical students, etc. You want everyone to stop associating your face with the "resident that is distracted on his/her phone all day long" and replace it with the "resident that is obsessed with multiple sclerosis and won't shut up about it".

 

[futureapppsy2]

@IonClaws , any updates?

 

[IonClaws]

@IonClaws , any updates?

Thanks for asking.

I was put on probation this past December and continued to work hard on rotations, learned a lot and did eventually start Adderall on top of Strattera. At my semi annual review in June, it was decided that I would remain on probation for some of the same issues (still behind my peers in clinical reasoning/applying clinical knowledge).

Thankfully, they promoted me to 3rd year because my ability to recognize emergent patient problems, ability to empathize with patients, and clinical reasoning all improved significantly.

I also did night float every Friday evening after my day shift with a senior last month, I did most of the work and got pretty good feedback. I did a week of nights alone a few weeks later and got pretty good feedback on that, I was told to "keep an open mind" about differential diagnosis (hard to do at times on night float, but not always).

So, overall, although things still need improvement and aren't fully resolved, they are headed in the right direction. I just need to stay frosty because I'm still on probation.

 

[ThoracicGuy]

Thanks for asking.

I was put on probation this past December and continued to work hard on rotations, learned a lot and did eventually start Adderall on top of Strattera. At my semi annual review in June, it was decided that I would remain on probation for some of the same issues (still behind my peers in clinical reasoning/applying clinical knowledge).

Thankfully, they promoted me to 3rd year because my ability to recognize emergent patient problems, ability to empathize with patients, and clinical reasoning all improved significantly.

I also did night float every Friday evening after my day shift with a senior last month, I did most of the work and got pretty good feedback. I did a week of nights alone a few weeks later and got pretty good feedback on that, I was told to "keep an open mind" about differential diagnosis (hard to do at times on night float, but not always).

So, overall, although things still need improvement and aren't fully resolved, they are headed in the right direction. I just need to stay frosty because I'm still on probation.

Not sure what happened to my original reply but:

Great job on the improvement. Just make sure you don't let up when it feels the heat may be off of you. You'll be under the microscope the rest of your time in training. Keep pushing forward.