"Quiet student" and its implications

[Blue Frog]

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I have twice now received the comment on my final evaluation that I was "quiet." The rest of my evaluations are generally pretty good. (Of course in my opinion I am just one of the students who talks when it seems appropriate, or when they have something to add that isn't already obvious to the attending and resident...and actually in both cases I felt that I was no more quiet than the other students I was working with.) Regardless of the reasoning, I am wondering how common this sort of comment is and and how residency directors view these comments. I am concerned now that this comment will come up on yet another evaluation.
Any comments appreciated.

 

[raidermedic]

I hate comments like this that have no actual meaning and left up to the reader to interpret. If a student didn't speak up when needed for patient care that should be noted. But if a student doesn't want to chat with an attending about a fish he caught that was "this big" he shouldn't have that commented on his evaluation.

IMO I don't think comments like that matter in most nonsurgical specialties. But in surgery where they covet assertiveness more so than other specialties the remark of "Quiet Student" is indeed a negative thing.

 

[Hard24Get]

I hate comments like this that have no actual meaning and left up to the reader to interpret. If a student didn't speak up when needed for patient care that should be noted. But if a student doesn't want to chat with an attending about a fish he caught that was "this big" he shouldn't have that commented on his evaluation.

IMO I don't think comments like that matter in most nonsurgical specialties. But in surgery where they covet assertiveness more so than other specialties the remark of "Quiet Student" is indeed a negative thing.

Yes, "quiet" is fine for Medicine, Radiology, Pathology, etc, etc, but if you are going into Surgery or EM you should hope those comments don't slip into your deans letter, or at least have LORs from folks that think otherwise.

In general, why don't you try to ask a few more questions? You can't possibly understand everything that goes on in clinical medicine everyday....

 

[ericdamiansean]

I got "competent" instead of a higher grade of "good" for one of my evals. It's because the person who evaluated me was an extrovert, and it wasn't my personality to talk too much, I wouldn't be the first to voluntarily answer a question unless no one else knew the answer but those who did talk alot (and most of it was bulls**t, and it's annoying when a question is meant for another person but he/she just shouts out the answer before the person whom the question was meant for actually answered it) received a "good" grade from him.
Mind you, one of these people who talked alot, also received an "excellent" grade for procedures when he didn't even know how to set a proper cannula, whereas I was given a "good" when in the wards, the nurses would ask me for my help whenever there was a difficult line/venepuncture. I was too lazy to argue with him for a higher grade though because I knew that in real life, I would function way better than the other fellas.

I would feel that as long as it doesn't affect you too much academically, don't worry about it. Most importantly, know your stuff and have your hands work well. Your actions will always speak more than your words.

 

[Hard24Get]

Your actions will always speak more than your words.

But didn't the story you told above speak against this proverb??? You had great action, but were not acknowledged for them. It may not be fair, but quiet people often get screwed.

 

[ericdamiansean]

But didn't the story you told above speak against this proverb??? You had great action, but were not acknowledged for them. It may not be fair, but quiet people often get screwed.

As a student, yes, being quiet might get you screwed, but those who have the ability to see through one's external character, he/she will know who the truly better and more talented students are. Sometimes, I guess people who talk alot are compensating for the lack of knowledge/ability. But when you are working, your work usually speaks for itself. Being a medical student, in comparison to a practicing doctor, is very different. Honestly, I think that you would rather have team mate who talks less but gets the job done rather than someone who talks alot but does the minimal or worse still, you have to clean up after them.

My dean is a good example. A very quiet, soft spoken man, but he is an amazing pediatric surgeon.

Nevertheless, as a final year student, I have been chosen, yup, not volunteered but asked to, in front of other students,to assist in countless surgeries, and as an active assistant, not a "retractologist". I have done miles of suturing, put in central lines, done peritoneal taps, chest tubes, hundreds of venepunctures,IV lines,ABGs, even did some lap chole manipulation..all by opening my mouth whenever necessary. Most students in my school probably had done less than 5% of what I have done.

 

[Blue Frog]

Yes, "quiet" is fine for Medicine, Radiology, Pathology, etc, etc, but if you are going into Surgery or EM you should hope those comments don't slip into your deans letter, or at least have LORs from folks that think otherwise.

In general, why don't you try to ask a few more questions? You can't possibly understand everything that goes on in clinical medicine everyday....

Unfortunately I DO want to go into EM. And the comments ARE on my transcript/MSPE. 🙁 I totally didn't see this coming...I'm so bummed out.

 

[ericdamiansean]

Unfortunately I DO want to go into EM. And the comments ARE on my transcript/MSPE. 🙁 I totally didn't see this coming...I'm so bummed out.

Have you completed your electives? There is a way to salvage this. Get into a fantastic elective program, somewhere in Africa (I should be able to find the contacts somewhere in my PC), and do extremely well there. Your log book will look pretty impressive for an EM match when you have something like
a) Bullet removal=30
b) Suturing machete wound=50😀

 

[Blue Frog]

Have you completed your electives? There is a way to salvage this. Get into a fantastic elective program, somewhere in Africa (I should be able to find the contacts somewhere in my PC), and do extremely well there. Your log book will look pretty impressive for an EM match when you have something like
a) Bullet removal=30
b) Suturing machete wound=50😀

Log book? Are you serious about all of this? I will be doing two EM rotations, one at a major county hospital (I'm not sure if we get involved with the traumas, however)

 

[Bertelman]

I would think most PDs will see this for what it is- a highly subjective assessment. "Quiet" is a relative term, judged against both the personality of the evaluator as well as the other students on the team during that rotation. I have completed rotations where I quietly marched along the team, not wanting to be noticed, or I have been the "lead" student, stepping forward to do whatever I thought was necessary. I chose my behavior based on my surroundings.

Point is, this isn't the kind of loose comment that will impair your ability to obtain interviews. Just make sure you aren't perceived as quiet or lacking assertiveness during the interview.

 

[Blue Frog]

I would think most PDs will see this for what it is- a highly subjective assessment. "Quiet" is a relative term, judged against both the personality of the evaluator as well as the other students on the team during that rotation. I have completed rotations where I quietly marched along the team, not wanting to be noticed, or I have been the "lead" student, stepping forward to do whatever I thought was necessary. I chose my behavior based on my surroundings.

Point is, this isn't the kind of loose comment that will impair your ability to obtain interviews. Just make sure you aren't perceived as quiet or lacking assertiveness during the interview.

Thanks for giving me some hope...now I can sleep a little better tonight 🙂

 

[Medical123]

I had "quiet" all over my Dean's Letter in various forms. Yet, I managed to Match into my #1 program in Medicine. I was asked about being my being quiet at some of my interviews. I just simply answered that I was the type of person that didn't like to draw unnecessary attention to myself, but preferred to just do my work and concentrate on providing good patient care. However, when I feel strongly about something, I am the type of person to speak up and stand for what I believe in. Program directors seemed to like that answer and I got what I wanted for my residency training.

Evaluations during the 3rd and 4th year are very subjective. Some of your more talkative classmates may be getting the occasional "He is aggressive" comments. I know that some of my friends got those and I wouldn't necessarily have called these people aggressive, just very outgoing.

I don't think that one negative comment in your Dean's Letter will ruin your chances of getting the residency that you want, as long as the rest of your letter is fine. If you are interested in something like surgery or e-med, take electives early next year and get good letters of recommendation from faculty. A good rec about your knowledge base and work habits will go a long way in helping you to secure the residency that you want.

 

[Samir Desai]

Blue Frog brings up an important issue that I thought I would weigh in on from an attending perspective. It's also an issue I've researched and included as a mistake in my book. First, I will excerpt the mistake and then I'll comment on this issue as it pertains to BlueFrog and his plans to apply for EM residency.

Mistake # 168 - Allowing shyness to affect your evaluation

Every year, there are many excellent students whose evaluations suffer because they are shy. Many attendings find it difficult to evaluate the shy student, and may draw erroneous conclusions. Is the student quiet because of his personality? Or is the student quiet because he lacks interest, motivation, or knowledge? Such students need to make a conscious effort to participate and be heard.

Did you know... In a study evaluating problem students, clerkship coordinators, clinical faculty members, and residents were asked to identify the frequency with which certain problem types were encountered. Among 21 problem students, the "excessively shy, nonassertive" student was the second most frequently encountered problem type in obstetrics and gynecology, the fourth in surgery, and the fifth in internal medicine, pediatrics, and psychiatry (Tonesk X, Buchanan RG. An AAMC pilot study by 10 medical schools of clinical evaluations of students. J Med Educ 1987; 62(9): 707-718).

From Page 160 of the 250 Biggest Mistakes 3rd Year Medical Students Make And How To Avoid Them (copyright 2007 by Samir P. Desai and Rajani Katta).


Now to comment on some specific points:

1) BlueFrog was wondering how often the comment "quiet" finds its way onto evaluation forms/MSPE. As someone who has reviewed many MSPEs as a member of a residency selection committee, I can tell you that it is common.

2) When I come across "quiet," I look to see if it's just a single comment in one rotation or if it's something that has been written in multiple clerkships. If it's the latter, it's something that I make note of. I then look at the letters of recommendation to see if it's something that the letter writer may have written about. Finally, I'll bring it up at an interview. Why? Because I would like to know if it's just that person's personality or, as I wrote in the mistake above, does it reflect a problem of some sort such as a lack of interest or motivation.

3) BlueFrog, you stated that your evaluations have been "pretty good." What about your evaluations in which the word "quiet" appeared? Were these equally as good? What was your overall rating on these evaluations? You can be "quiet" and receive a good evaluation if the attending concluded that you were "quiet" because of personality. On the other hand, your evaluation may suffer if the attending drew a different conclusion about you being "quiet."

4) BlueFrog wrote "...and actually in both cases I felt that I was no more quiet than the other students I was working with." In studies that have been done evaluating the self-assessment skills of students, we've learned that students are not the best judge of their performance. Therefore, I would recommend that you specifically ask your attending or resident about how you are coming across in a mid-rotation meeting. "Do you feel that I am participating enough in rounds?" would be a reasonable question to ask. Then if you learn that they would like you to participate more, you can do so in the remainder of the rotation. This will decrease the likelihood that the word "quiet" will find its way into your evaluation.

5) Hard24get wrote "In general, why don't you try to ask a few more questions? You can't possibly understand everything that goes on in clinical medicine everyday...." Excellent advice. Are you asking enough questions? As an attending, I've found that students don't ask as many questions as they should. If you're having a hard time coming up with questions, you might consider developing a questioning plan for rounds the evening before.

6) ericdamiansean wrote "As a student, yes, being quiet might get you screwed, but those who have the ability to see through one's external character, he/she will know who the truly better and more talented students are. Sometimes, I guess people who talk alot are compensating for the lack of knowledge/ability. But when you are working, your work usually speaks for itself."

As an attending, I have to draw conclusions about a student's cognitive and noncognitive skills largely through my interactions with the student during attending rounds. In other words, you may be assertive and talkative but, if you don't show me that in rounds, how would I come to that conclusion?

7) In summary, I would not lose sleep over the fact that the word "quiet" has appeared in several evaluations. But I would try to determine why it is appearing. What can you do differently? Is it affecting your overall evaluation? Might you have done even better if you weren't perceived as "quiet?" These are important questions to answer for future rotations.

8) Before interviews, I would have a strategy in place to answer any queries you may receive regarding the comment.

9) Finally, as someone who plans to pursue a career in EM, keep in mind that letter writers will often use the SLOR form for EM (standardized letter of recommendation). On that form, the letter writer is asked to rate personality. The choices are:

Superior Good Quiet Poor

Here is the link to the form:

http://www.saem.org/saemdnn/Home/ViewByRole/MedicalStudents/SLORForms/tabid/195/Default.aspx


Best of luck, BlueFrog.

 

[AmoryBlaine]

Yes, "quiet" is fine for Medicine, Radiology, Pathology, etc, etc, but if you are going into Surgery or EM you should hope those comments don't slip into your deans letter, or at least have LORs from folks that think otherwise.

In general, why don't you try to ask a few more questions? You can't possibly understand everything that goes on in clinical medicine everyday....

Eh, maybe. I think these "specialty stereotypes" are way overblown. One of the newest attendings in my home institution's ED (read: newest grad) is practically mute. When you meet her she seems alot more like a Psychiatrist or Pediatrician. A few of the other docs have described her to me as being scary good.

To the OP: go for it if you want it. Talk to a good advisor about these issues.

 

[emrevue]

my first rotation in IM I also got the dreaded "quiet" comment during my midrotation feedback from my resident. then i realized:

what they don't teach you in med school is how to sell yourself. you have to make sure your residents and attendings see your best attributes and be proactive about your own learning, because they definitely don't have time to sort that out.

so, what i started doing was pretty much telling almost everything i was doing in regards to the clerkship short of when i was going to the bathroom. there is definitely an art to this, but it sounds like you could be a little more on the end of the spectrum.

did you read an article on kidney failure in the NEJM last night because your patient has kidney failure? bring it up on rounds. hand it out if you thought there was a good point. did you spend an extra hour talking to your patient about whatever? bring it up to your resident or attending.

the point is, even if you do the work, if no one witnesses it, it's like it never happened. people don't question who did the work on a hospital team, they only question when it didn't get done.

once i started doing this, and trying to put myself in a good light (but never at the expense of other students), i started consistently getting honors grades. i had all along, i just needed to know how to use it! by the way, i am going into EM and just matched.

 

[AmoryBlaine]

my first rotation in IM I also got the dreaded "quiet" comment during my midrotation feedback from my resident. then i realized:

what they don't teach you in med school is how to sell yourself. you have to make sure your residents and attendings see your best attributes and be proactive about your own learning, because they definitely don't have time to sort that out.

so, what i started doing was pretty much telling almost everything i was doing in regards to the clerkship short of when i was going to the bathroom. there is definitely an art to this, but it sounds like you could be a little more on the end of the spectrum.

did you read an article on kidney failure in the NEJM last night because your patient has kidney failure? bring it up on rounds. hand it out if you thought there was a good point. did you spend an extra hour talking to your patient about whatever? bring it up to your resident or attending.

the point is, even if you do the work, if no one witnesses it, it's like it never happened. people don't question who did the work on a hospital team, they only question when it didn't get done.

once i started doing this, and trying to put myself in a good light (but never at the expense of other students), i started consistently getting honors grades. i had all along, i just needed to know how to use it! by the way, i am going into EM and just matched.

This is a really good post. Although I'm not quiet I definitely started going this after my first rotation. Not only does it make you look good but it keeps your team informed of what's going on. My favorite strategy is to read up on something overnight and then when I'm presenting on rounds just say, "so actually I read this article in X the other night and I wonder if we need to consider ..."

 

[arthrodisiac]

on my last rotation i also got the "quiet" comment, yet i still got a perfect score on the evaluation. so what the hell does this mean? nothing imo. i made an effort this time to always answer the question first, ask lots of questions, go to the head of the bed for every patient on teaching rounds and i am still quiet. I dont think there is any compromise. every student is either classified as too loud or too quiet. they have nothing else to write in the "needs improvement" section.

 

[TerrierToy]

I think that most medical students don't realize how subjective an evaluation on a clerkship can be. I have gotten excellent evaluations on rotations and allowed to do a large number of tasks on my own and able to talk about what I knew about medicine, whereas on others there is alot of "drama" going on between the residents, attendings and students, and it is frustrating to figure out how to socially play this game. Attendings like to believe that they have this magical power to look into the soul of a medical student who may or may not be doing an excellent job, in terms of work ethics, etc . . ., and give them a detailed evaluation. But honestly, emotions come into play, if an attending is joking about a certain patient or about their upcoming vacations plans and you don't chime in the right way then you are viewed as quiet and not part of the team although you are running around in the background doing alot of the work. Being a good attending clinically doesn't necessarily make one an excellent evaluator and educator of medical students. Most attendings have no formal training in the evaluation or education of medical students and appear to wing-it on the ward. Alot of attendings and residents have wasted my time by making me and groups of students listen to them talk about medically unrelated topics i.e. what they think of Britney Spears. There are alot of things that are "extras" which I felt I was doing as a med student, but not given credit for i.e. seeig extra patients, taking alot of time to help educate my patients, . . . but having less time and energy to hold the hand of the attending while they whine about x, y and z. The most hardworking students sometimes get burnt out in third year, while if you can socialize with the attending and residents constantly you may not be working quite as hard. Just remember some of these attendings were rude and arrogant little medical students, like some of our classmates . . .

 

[Blue Frog]

2) When I come across "quiet," I look to see if it's just a single comment in one rotation or if it's something that has been written in multiple clerkships. If it's the latter, it's something that I make note of. I then look at the letters of recommendation to see if it's something that the letter writer may have written about. Finally, I'll bring it up at an interview. Why? Because I would like to know if it's just that person's personality or, as I wrote in the mistake above, does it reflect a problem of some sort such as a lack of interest or motivation.

Best of luck, BlueFrog.

Thanks for the very thorough response...much appreciated.

In point #2 (above) are you implying that if it is someone's personality, then that is okay? Part of my concern is that one may assume this is my personality and that is a negative for EM.

Also, as the question has come up in several posts, I've received these two comments in two smaller rotations (not medicine or surgery) 1) a rotation that is least related to EM in an overall "blah" evaluation 2) a rotation that i received an otherwise excellent evaluation.

 

[ocean11]

Thanks for the very thorough response...much appreciated.

In point #2 (above) are you implying that if it is someone's personality, then that is okay? Part of my concern is that one may assume this is my personality and that is a negative for EM.

Also, as the question has come up in several posts, I've received these two comments in two smaller rotations (not medicine or surgery) 1) a rotation that is least related to EM in an overall "blah" evaluation 2) a rotation that i received an otherwise excellent evaluation.

Hey what's up?

If it makes you feel any better I don't think 'quiet' is so bad on an evaluation..... I've heard of students getting real $hitt& evals. Like this one guy I know in my class, after doing peds his attending wrote that he had terrible interpersonal communication skills. My other friend (who is now a family doctor) told me that on his OB/GYN rotation one of his comments was 'lack of interest' 'lack of enthusiasm' 'did not follow directions'. he had to repeat an extra month of OB/GYN in his 4th year! which really sucked!!!! so yeah... those are bad, but quiet... well really, its not the end of the world...if the rest of your evals are good you have nothing to worry about!! On my ER eval which was 3 sentences long.... the last sentence was "has average to above average medical knowledge compared to her classmates"... I didn't like the 'average' part.... that dosn't sound stellar either, but after listening to some of my friends, I'm not complaining...

GOOD LUCK, hope this rotation is going better for you 🙂

OCEAN11

 

[Hard24Get]

Eh, maybe. I think these "specialty stereotypes" are way overblown. One of the newest attendings in my home institution's ED (read: newest grad) is practically mute. When you meet her she seems alot more like a Psychiatrist or Pediatrician. A few of the other docs have described her to me as being scary good.

To the OP: go for it if you want it. Talk to a good advisor about these issues.

Absolutely the stereotypes are overrated, and any personality can thrive in practically any specialty. However, while some specialties would'nt even blink at the possibilty of someone being quiet, others might raise red flags at the prospect. This is well evidenced by Dr. Desai's post pointing out where "quiet" shows up in the SLOR rating. You can certainly skate by with it on your MSPE, but don't let it be on your SLOR.

 

[Blake]

I got the ''quiet'' comment too, in ortho. The eval was actually good, but I guess I don't fit the surgeon stereotype (or whatever that means). Oh well, my other surgery evals were better and I'll still be applying to surgery in a couple of months.

 

[Tired]

I got the ''quiet'' comment too, in ortho. The eval was actually good, but I guess I don't fit the surgeon stereotype (or whatever that means). Oh well, my other surgery evals were better and I'll still be applying to surgery in a couple of months.

Well obviously you can't be quiet on Ortho! C'mon, look at the guys who do it!

 

[Blake]

Well obviously you can't be quiet on Ortho! C'mon, look at the guys who do it!

Oh snap !

 

[AmoryBlaine]

Thanks for the very thorough response...much appreciated.

In point #2 (above) are you implying that if it is someone's personality, then that is okay? Part of my concern is that one may assume this is my personality and that is a negative for EM.

Also, as the question has come up in several posts, I've received these two comments in two smaller rotations (not medicine or surgery) 1) a rotation that is least related to EM in an overall "blah" evaluation 2) a rotation that i received an otherwise excellent evaluation.

I'd like to repeat my statement that specialty stereotypes are way overblown. Mostly the stuff of pre-clinical students and those on internet forums.

You will probably find that most people who go into EM are not "quiet." Then again, most people in medical school are not quiet. If by "quiet" you mean you are reserved and slightly laconic but know your stuff, you will probably be fine. If by "quiet" you mean that you are a shrinking violet who tends to be shy, it's going to be hard for you to shine. That doesn't mean that you don't have a chance, but I think you would be right to realize that it's not an advantage.

Think about all the orthos you know. If a small, shy girl who didn't like sports wanted to go into the field she would have an uphill battle. This might say some unflattering things about Ortho but I think everyone would admit that it's more open to the former quarterbacks than the chess team captain.

I mean think about it, when you do an EM rotation chances are your going to be working with a fresh group of people at least every few shifts. "Quietness" is probably not the ideal strategy for impressing a busy attending in a big ED.

 

[Blue Frog]

2) When I come across "quiet," I look to see if it's just a single comment in one rotation or if it's something that has been written in multiple clerkships. If it's the latter, it's something that I make note of. I then look at the letters of recommendation to see if it's something that the letter writer may have written about. Finally, I'll bring it up at an interview. Why? Because I would like to know if it's just that person's personality or, as I wrote in the mistake above, does it reflect a problem of some sort such as a lack of interest or motivation.

Best of luck, BlueFrog.

Thanks for the very thorough response...much appreciated.

In point #2 (above) are you implying that if it is someone's personality, then that is okay? Part of my concern is that one may assume this is my personality and that is a negative for EM.

Also, as the question has come up in several posts, I've received these two comments in two smaller rotations (not medicine or surgery) 1) a rotation that is least related to EM in an overall "blah" evaluation 2) a rotation that i received an otherwise excellent evaluation.

 

[closertofine]

If by "quiet" you mean that you are a shrinking violet who tends to be shy, it's going to be hard for you to shine. That doesn't mean that you don't have a chance, but I think you would be right to realize that it's not an advantage.

Just hypothetically, what should one do in this situation? Go into pathology?

 

[AmoryBlaine]

Just hypothetically, what should one do in this situation? Go into pathology?

Go into whatever you want, just realize that your personality may not be the exact right fit for your field.

Can you be a shy surgeon? Sure. Are you going to be surrounded by shy people? No.

 

[ericdamiansean]

Log book? Are you serious about all of this? I will be doing two EM rotations, one at a major county hospital (I'm not sure if we get involved with the traumas, however)

If you do not have the opportunity to do much at an EM rotation, and you have not done an elective, then yes, an elective in EM in South Africa (provided you can afford it, it isn't that expensive) would be good. The experience there is amazing and it would really provide an additional boost regardless of you being "quiet"

 

[watermen]

If you do not have the opportunity to do much at an EM rotation, and you have not done an elective, then yes, an elective in EM in South Africa (provided you can afford it, it isn't that expensive) would be good. The experience there is amazing and it would really provide an additional boost regardless of you being "quiet"

It does not work in the US that way. A rotation outside the US can only be something that add on to your CV to make your interview more interesting....it basically has no impact on your residency application, unless you work with some super world renown nobel prize winner doctor....but you are not likely to find a world renown doctor in south africa.

To get into specialty of your choice in the US, you need to do a rotation in the US of that specialty even if you are a US medical student. so it really makes no sense at all for any US student to do a rotation in another country during the prime time of their residency process.

 

[ericdamiansean]

so it really makes no sense at all for any US student to do a rotation in another country during the prime time of their residency process.

How about as a student? Perhaps some schools allow their students to explore elective options in other countries

 

[Zuwie]

This is America! You have freedom of speech and freedom of NOT SPEECH! If anybody says you are too quiet, they can GO TO HELL and stay there. And if they continue to say you are quiet, you can quietly kick their loud ass!

This is my "got hammered after celebrating med school graduation" post.

 

[Samir Desai]

Thanks for the very thorough response...much appreciated.

In point #2 (above) are you implying that if it is someone's personality, then that is okay? Part of my concern is that one may assume this is my personality and that is a negative for EM.

Also, as the question has come up in several posts, I've received these two comments in two smaller rotations (not medicine or surgery) 1) a rotation that is least related to EM in an overall "blah" evaluation 2) a rotation that i received an otherwise excellent evaluation.

Many physicians who are "quiet" are successful. Case in point would be ericdamiansean's example of his dean who he describes as a "quiet, soft-spoken man."

I understand that some students have a "quiet" personality. That doesn't mean that they lack interest or motivation. My point is that it can sometimes be hard to tell unless an attending makes an active effort.

As an attending, when I have a quiet student, I make an effort to engage the student in discussion about his patients, about other patients, etc. Why? Because I don't want to draw any erroneous conclusions.

Do all attendings do that? No. Some may jump to the wrong conclusion. That's why I agree wholeheartedly with emrevue's comments on selling yourself and making sure those around you see your best attributes.

Of course, there's a right way to sell yourself and a wrong way. Dominating rounds and making other people look bad are obviously the wrong ways. As some of the others have mentioned, there are ways to increase your level of participation during attending rounds without stepping on anyone's toes.

My recommendation to you, Blue Frog, would be to increase your level of participation during rounds. This will decrease the likelihood of your EM attendings jumping to the wrong conclusions about you. Then in the SLOR, they can circle something besides "quiet."

 

[watermen]

How about as a student? Perhaps some schools allow their students to explore elective options in other countries

I think most school allow students to do elective in another country. And i know some students do it...but they do it after they got their letter and have the free time...not do it to get letters. In fact i m thinking of doing one.

 

[ericdamiansean]

I think most school allow students to do elective in another country. And i know some students do it...but they do it after they got their letter and have the free time...not do it to get letters. In fact i m thinking of doing one.

But you would agree that perhaps, even just a little, that a letter would do you good?

 

[AmoryBlaine]

But you would agree that perhaps, even just a little, that a letter would do you good?

Probably not. Most other countries have very different systems of training.

 

[berkeleyboy]

you know what one of my friends does. He actively goes up to the attendings and residents (who's in charge of evaluating him of course) and asks them what they think are important topics that he should go home and read about. Than he asks if he can talk about what he read with the attending/resident the next day. This seemed to work for him landing him many honors evals during his 3rd year. This seemed to work for the following reasons:

1) it shows your interested in the field

2) it shows you are reading

3) by diverging your attending/residents pimp questions to a predetermined topic, you have a heads up on what he's going to ask you about tomorrow and it will minimize the randomness of pimp questions that you can be asked.

4) you can basically use this strategy on every rotation and every attending/resident, it shows you value their opinion and validates their status as a mentor/teacher.

5) its a completely perfect way to break the ice and basically gives you one on one time with the person evaluating you.

Good stuff. hopes this helps the quiet ones.

Berk

 

[Barry Otter]

During my clerkships, it was the medicine attendings, for whatever reason, who were the most eager to give me formal, unsolicited feedback, always with an air of quasi-religious solemnity. I do not know why this is, but the ritual was always patterned off a script that has no doubt been passed down in secrecy to newly minted attendings from the time of Osler, or maybe Galen, to the present:

A. The attending announces, to her resident, secretary, or if there's no one nearby to receive her promulgation, then the universe at large, that she will now momentarily retire from her clinical duties in order to evaluate the medical student.

B. The attending proceeds to find a janitor's closet in which I will be evaluated.

C. She takes out a standard form and begins a recitation of an overall assessment of my performance. The look of unshakable certainty in her eyes is identical to the one seen when she is reciting an obscure fact of no medical relevance which she somehow retained from the Nov. 19, 1994 issue of NEJM article on uncontrollable flatulence (no doubt her own attending made her read it during her residency). Then comes the litany of the particulars.
a) "Patient interaction." She expertly explores and dissects the details of my bedside manners. This despite the fact that she has never been in the same room with me as I see a patient, except during rounds when she is putting in nominal face time with the patient, and during which time I am, in fact, doing nothing other than nodding and smiling as she conducts a perfunctory physical exam (was there ever a time to read DeGowin's? Not during the sleepless hours of her residency, and certainly not as an attending, now that she has multiple demands on her time. There are articles to be read and written, charting to be done, and evaluations to conduct!) or tells that well-worn joke for the nth time this month.
b) "Fund of knowledge." Usually based on patient presentations (inpatient setting) or pimping questions (outpatient setting). I don't remind her that I keep quiet when she quotes poorly designed studies that are statistical disasters as holy writ, or quotes outright untruths like the elevation of PSA after a digital exam.
c)"Enthusiasm." I am cautioned that I could show more enthusiasm. I wonder how this nebulous quality of visible "enthusiasm" that I am being evaluated on directly translates to patient care, which is why I'm in medical school in the first place. No one has satisfactorily addressed this point for me. I am reminded that, in the future, one way I could show more enthusiasm is by bringing in articles. I will do no such thing when all you're going to do is disrespect the trees that have shed their lives for you by lazily skimming only the conclusion and tossing it in the trash with the remainders of your lunch.
d)"Curiosity/motivation" She marches on undeterred with a critique of said attributes. I tune out, especially since I'm the most curious person I know.
e)At this point, I find that my eyes cannot roll back far enough. The idea of attendings evaluating their students in such detail, particularly based on typically limited interactions, is comical, and frankly insulting. More importantly, this sort of theater can have NO meaningful impact on one's education. No positive impact, in any case.
I tell the attending that while I thank her for her time, that my compass has always been internal, and other people's opinions seldom have a bearing on my actions on the ward. The attending either wears a befuddled look complete with furrowed brows and narrowed eyes, or naively asks me if I would like to be more open to input.


No man is an island, of course, and we are all susceptible to blind spots. But the educational goals for a medical student aren't complicated: treat patients conscientiously, and take your education, especially self-education, seriously.
In no other rotation was I subjected to this odd evaluation ritual, I suspect partly because most faculty realize on some level that evaluation business is a game. And it is fine to treat it as an unavoidable game (which I don't think it is, but that's a separate discussion), but let's not make it more than it is.

Samir Desai, I read your book and hope that you don't subject your own students to this absurd theater or at least leave out the pontifical undertones.

Blue Frog brings up an important issue that I thought I would weigh in on from an attending perspective. It's also an issue I've researched and included as a mistake in my book. First, I will excerpt the mistake and then I'll comment on this issue as it pertains to BlueFrog and his plans to apply for EM residency.

Mistake # 168 - Allowing shyness to affect your evaluation

Every year, there are many excellent students whose evaluations suffer because they are shy. Many attendings find it difficult to evaluate the shy student, and may draw erroneous conclusions. Is the student quiet because of his personality? Or is the student quiet because he lacks interest, motivation, or knowledge? Such students need to make a conscious effort to participate and be heard.

Did you know... In a study evaluating problem students, clerkship coordinators, clinical faculty members, and residents were asked to identify the frequency with which certain problem types were encountered. Among 21 problem students, the "excessively shy, nonassertive" student was the second most frequently encountered problem type in obstetrics and gynecology, the fourth in surgery, and the fifth in internal medicine, pediatrics, and psychiatry (Tonesk X, Buchanan RG. An AAMC pilot study by 10 medical schools of clinical evaluations of students. J Med Educ 1987; 62(9): 707-718).

From Page 160 of the 250 Biggest Mistakes 3rd Year Medical Students Make And How To Avoid Them (copyright 2007 by Samir P. Desai and Rajani Katta).


Now to comment on some specific points:

1) BlueFrog was wondering how often the comment "quiet" finds its way onto evaluation forms/MSPE. As someone who has reviewed many MSPEs as a member of a residency selection committee, I can tell you that it is common.

2) When I come across "quiet," I look to see if it's just a single comment in one rotation or if it's something that has been written in multiple clerkships. If it's the latter, it's something that I make note of. I then look at the letters of recommendation to see if it's something that the letter writer may have written about. Finally, I'll bring it up at an interview. Why? Because I would like to know if it's just that person's personality or, as I wrote in the mistake above, does it reflect a problem of some sort such as a lack of interest or motivation.

3) BlueFrog, you stated that your evaluations have been "pretty good." What about your evaluations in which the word "quiet" appeared? Were these equally as good? What was your overall rating on these evaluations? You can be "quiet" and receive a good evaluation if the attending concluded that you were "quiet" because of personality. On the other hand, your evaluation may suffer if the attending drew a different conclusion about you being "quiet."

4) BlueFrog wrote "...and actually in both cases I felt that I was no more quiet than the other students I was working with." In studies that have been done evaluating the self-assessment skills of students, we've learned that students are not the best judge of their performance. Therefore, I would recommend that you specifically ask your attending or resident about how you are coming across in a mid-rotation meeting. "Do you feel that I am participating enough in rounds?" would be a reasonable question to ask. Then if you learn that they would like you to participate more, you can do so in the remainder of the rotation. This will decrease the likelihood that the word "quiet" will find its way into your evaluation.

5) Hard24get wrote "In general, why don't you try to ask a few more questions? You can't possibly understand everything that goes on in clinical medicine everyday...." Excellent advice. Are you asking enough questions? As an attending, I've found that students don't ask as many questions as they should. If you're having a hard time coming up with questions, you might consider developing a questioning plan for rounds the evening before.

6) ericdamiansean wrote "As a student, yes, being quiet might get you screwed, but those who have the ability to see through one's external character, he/she will know who the truly better and more talented students are. Sometimes, I guess people who talk alot are compensating for the lack of knowledge/ability. But when you are working, your work usually speaks for itself."

As an attending, I have to draw conclusions about a student's cognitive and noncognitive skills largely through my interactions with the student during attending rounds. In other words, you may be assertive and talkative but, if you don't show me that in rounds, how would I come to that conclusion?

7) In summary, I would not lose sleep over the fact that the word "quiet" has appeared in several evaluations. But I would try to determine why it is appearing. What can you do differently? Is it affecting your overall evaluation? Might you have done even better if you weren't perceived as "quiet?" These are important questions to answer for future rotations.

8) Before interviews, I would have a strategy in place to answer any queries you may receive regarding the comment.

9) Finally, as someone who plans to pursue a career in EM, keep in mind that letter writers will often use the SLOR form for EM (standardized letter of recommendation). On that form, the letter writer is asked to rate personality. The choices are:

Superior Good Quiet Poor

Here is the link to the form:

http://www.saem.org/saemdnn/Home/ViewByRole/MedicalStudents/SLORForms/tabid/195/Default.aspx


Best of luck, BlueFrog.

 

[velo]

One thing I've learned 3rd year is that, for better or worse, a large part of doing well is simply getting the people on your team to "like you." If you're well liked by the team when they go to evaluate you they will remember the times you were on the ball with patient care, or knew some obscure fact, or did a procedure well and will forget the times you were less than stellar. That said, I think a big part of "being liked" is being personable and shooting the **** with the people around you. If you're quiet you come off as disinterested and it makes it harder to like you.

 

[Tired]

I tell the attending that while I thank her for her time, that my compass has always been internal, and other people's opinions seldom have a bearing on my actions on the ward. The attending either wears a befuddled look complete with furrowed brows and narrowed eyes, or naively asks me if I would like to be more open to input.

I learned quickly that the best way to shut down these kinds of evals was to say, "Actually, I'm interested in surgery." This is usually followed by the attending attempting to justify why I should care about their field:

"Well, as a surgeon, you will have a lot of psychiatric patients."
"As a surgeon, you will see many patients with diabetes."
"There are very many geriatric patients on surgical services."

I then immediately followup with, "Yes, that's why they consult you."

That's usually the end of the eval.

 

[velo]

During my clerkships, it was the medicine attendings, for whatever reason, who were the most eager to give me formal, unsolicited feedback, always with an air of quasi-religious solemnity.

Oh please, are you honestly going to complain about an attending who takes time out of their no doubt busy schedule to give you feedback about your performance on the rotation and try to help you improve as a physician? I'll take that attending any day of the week over a surgery attending who doesn't even seem aware that there is a med student on their service, and refers to you only as "hey you" as they ask you to suction, cut suture, or move out of the way...

 

[Barry Otter]

Oh please, are you honestly going to complain about an attending who takes time out of their no doubt busy schedule to give you feedback about your performance on the rotation and try to help you improve as a physician? I'll take that attending any day of the week over a surgery attending who doesn't even seem aware that there is a med student on their service, and refers to you only as "hey you" as they ask you to suction, cut suture, or move out of the way...

Before I respond to this, let me quote the following observation from Samir Desai's post.

As an attending, I have to draw conclusions about a student's cognitive and noncognitive skills largely through my interactions with the student during attending rounds. In other words, you may be assertive and talkative but, if you don't show me that in rounds, how would I come to that conclusion?

This is a fairly typical ward scenario, and so is what I said above about attendings evaluating my patient interaction skills. So it all the more begs the question of what business attendings have in trying to give me feedback that is based on fleeting interactions and gossamer impressions. The point, one which I apparently failed to make sufficiently clear the first time around, is that these arbitrary and barely, if at all, substantiated feedback sessions have never helped me become a better physician in the slightest. It would be a different matter if an attending who's had extensive interaction with me noticed some deficits and gives appropriate constructive criticism. But that isn't the case here. The reality of the situation is that for the sake of department's requirements and residency applications, evaluations must be made. And it is okay to acknowledge this reality. What's hypocritical is trying to fashion a porterhouse steak from ground beef. Given the limited nature of attending-student interactions in medicine, the seriousness with which these evals are undertaken verges on sanctimonious and crosses far into comedy, and more than hints at hypocrisy.

It sounds like you and I have had different experiences in our rotations. Many of my best teachers during third year were surgery attendings. For the most part, they had admirable bedside manners, learned their students' names, and took the time to teach me. Sorry if your experience was less positive than mine.

 

[AmoryBlaine]

I learned quickly that the best way to shut down these kinds of evals was to say, "Actually, I'm interested in surgery." This is usually followed by the attending attempting to justify why I should care about their field:

"Well, as a surgeon, you will have a lot of psychiatric patients."
"As a surgeon, you will see many patients with diabetes."
"There are very many geriatric patients on surgical services."

I then immediately followup with, "Yes, that's why they consult you."

That's usually the end of the eval.

I truly hate this game of "you're going to need to know this regardless of what field you go into."

No, actually, if I'm an orthopaedist/ENT/radiology/etc I don't need to know how to manage depression. Recognizing it might be nice, but you can teach someone to recognize MDD in 5 minutes.

 

[Tired]

I truly hate this game of "you're going to need to know this regardless of what field you go into."

No, actually, if I'm an orthopaedist/ENT/radiology/etc I don't need to know how to manage depression. Recognizing it might be nice, but you can teach someone to recognize MDD in 5 minutes.

Agreed. They expect every student to learn about their field, but get incredibly indignant when other specialties try to treat "their" diseases. In my 3rd year, this was primarily a Medicine problem. The surgeons just wanted the Medicine-oriented students to learn when they need to call a surgeon, and that was about it. But on Medicine, the surgery-oriented students were expected to be "enthusiastic" when discussing JNC7 recommendations. Bleah.

And regarding an earlier post: I also found my best and most honest evals came from the surgeons. Surgery gave me a straight up eval (and not entirely good) with no B.S. FP was okay. The rest were filled with generic evaluations, cliche catch phrases, and minimal real feedback.

Psych was the worst - none of my residents and only two attendings (out of 6) turned in the written eval of me, yet my course coordinator was comfortable giving me a "pass" for the clerkship, even though I got a 99 on the shelf. That one I actually challenged, and successfully.

 

[velo]

Before I respond to this, let me quote the following observation from Samir Desai's post...

No I had some good surgery attendings, I just also had some like I described-- the polar opposite of the attending you described-- and between the two I'll take the one who provides feedback. Even if I think the majority of it is crap (which it usually isn't) if I'm honest with myself I can usually pull at least some useful information about my strengths and weaknesses out of it.

Your post just strikes me as overly defensive, and while I can certainly relate the the experience of being evaluated by someone with whom you've had minimal interaction, such is the nature of medical education. And its not an issue that's going to go away in residency or even the rest of our careers. People are constantly judged by those around them based on limited, subjective, and possibly skewed interactions-- so I think at the very least its important to understand the kinds of impressions people get from me even from fleeting interactions.

 

[AmoryBlaine]

Agreed. They expect every student to learn about their field, but get incredibly indignant when other specialties try to treat "their" diseases. In my 3rd year, this was primarily a Medicine problem. The surgeons just wanted the Medicine-oriented students to learn when they need to call a surgeon, and that was about it. But on Medicine, the surgery-oriented students were expected to be "enthusiastic" when discussing JNC7 recommendations. Bleah.

And regarding an earlier post: I also found my best and most honest evals came from the surgeons. Surgery gave me a straight up eval (and not entirely good) with no B.S. FP was okay. The rest were filled with generic evaluations, cliche catch phrases, and minimal real feedback.

Psych was the worst - none of my residents and only two attendings (out of 6) turned in the written eval of me, yet my course coordinator was comfortable giving me a "pass" for the clerkship, even though I got a 99 on the shelf. That one I actually challenged, and successfully.

Good for you!

Score one for the medical students.

 

[ericdamiansean]

How about this then?
During my obgyn rotation,I was scrubbing in for a TAHBSO, when halfway, the guy asked me "Are you going into medicine, surgery or obgyn?" I answered "medicine" and his next reply was "This is the last surgery that you'll be scrubbing in with me in the future"..what the heck!!!

 

[Barry Otter]

No I had some good surgery attendings, I just also had some like I described-- the polar opposite of the attending you described-- and between the two I'll take the one who provides feedback. Even if I think the majority of it is crap (which it usually isn't) if I'm honest with myself I can usually pull at least some useful information about my strengths and weaknesses out of it.

Your post just strikes me as overly defensive, and while I can certainly relate the the experience of being evaluated by someone with whom you've had minimal interaction, such is the nature of medical education. And its not an issue that's going to go away in residency or even the rest of our careers. People are constantly judged by those around them based on limited, subjective, and possibly skewed interactions-- so I think at the very least its important to understand the kinds of impressions people get from me even from fleeting interactions.

Hahaha, why the indignation, starting with "Oh, please"? Are going into medicine or something?

You're right that people make judgments based on fleeting impressions all the time, but I guess I don't understand why those should have any bearing on what I do as a medical student. The idea of someone giving me feedback -- whose alleged purpose is to help me grow as a physician -- based on superfial interactions, and whether I brought in articles, and to take it seriously and deceiving himself into believing that there is any substance behind this empty ritual, this I find laughable.

You say "such is the nature of medical education" but I think the system is ineffective in a lot of ways and does not need to be the way it is. On the one hand, I'm often thinking about ways things could be improved; on the other, I'm quick to pounce on hypocrisy and sanctimony. There; that bit of self-critique is more penetrating than any half-digested platitude that I ever heard come out of a medicine attending's mouth.

 

[velo]

Hahaha, why the indignation, starting with "Oh, please"? Are going into medicine or something?

You're right that people make judgments based on fleeting impressions all the time, but I guess I don't understand why those should have any bearing on what I do as a medical student. The idea of someone giving me feedback -- whose alleged purpose is to help me grow as a physician -- based on superfial interactions, and whether I brought in articles, and to take it seriously and deceiving himself into believing that there is any substance behind this empty ritual, this I find laughable.

You say "such is the nature of medical education" but I think the system is ineffective in a lot of ways and does not need to be the way it is. On the one hand, I'm often thinking about ways things could be improved; on the other, I'm quick to pounce on hypocrisy and sanctimony. There; that bit of self-critique is more penetrating than any half-digested platitude that I ever heard come out of a medicine attending's mouth.

Well I'm torn between gyn oncology and cards so I kind of straddle the medicine/surgery line.

I don't mean to be indignant, I just think you're being rude. This probably all stems from the two of us having very different clinical experiences. I've always found that after presenting on rounds and writing full H&Ps for medicine attendings they get a good sense of my depth of knowledge and I really appreciate it when they volunteer to give me feedback rather than forcing me to chase them down to fill out our horrible little mandatory feedback cards. I've never felt as though any of the feedback was sanctimonious and felt as though they were able to identify areas in which they were unable to directly assess my ability (i.e. patient interactions). The evaluations from medicine attendings were the longest that have been written about me this year and after reading them I felt like they knew me pretty well. In contrast I've had some other attendings (primarily in surgical subspecialties...ortho in particular) who seem only partially aware students are on their service--"who is this person and why do I keep running into him this week?"-- who really didn't teach me a thing and whose only feedback was "well, how do you think you're doing?"

Obviously, this wasn't your experience. But for me, given the choice, I'd rather have too much feedback than too little. I'm fine with filtering out feedback that I think is baseless, but I'd prefer to have something to work with. So when I hear someone responding with open contempt to an attending taking time out of their schedule to let their student know how they think they're doing, I think it's rude. And it gets under my skin because I'd rather not discourage attendings from acknowledging their student's existence.

But no worries, I think we just had some different experiences that led to some different frustrations.

 

[velo]

How about this then?
During my obgyn rotation,I was scrubbing in for a TAHBSO, when halfway, the guy asked me "Are you going into medicine, surgery or obgyn?" I answered "medicine" and his next reply was "This is the last surgery that you'll be scrubbing in with me in the future"..what the heck!!!

That's unacceptable. In my humble opinion you should not ask a student that question unless you're prepared to respond, "Ah, <blank> is a wonderful field" to whatever they say. Where does he get off? When I started my gyn onc rotation I was fairly certain I was going into medicine and was asked that question. The fellow responded that medicine was great and didn't treat me any differently. By the end of the rotation I had enjoyed gyn onc so much I decided to come back for a sub-I this coming year. If he had responded like yours had it probably would have turned me off the whole field...just a bone-headed thing to say...