Regaining perspective after a bad Review

[peiyueng]

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Guys: I am being told by the Chief resident that "They" the top (i.e. the program director) has concerns about me academically.

At first this was very devastating. I mean I had always thought that I was doing pretty well. It isn't me just being grandiose--I reality checked myself--I am reaching patients; I am getting through to very difficult patients about their med compliance. I work extra hours trying to talk to both the patient and the families so that there is a coherent story. This is especially important when schizophrenic patients have no clue why they are about to be kicked out of their apartment (i.e. their insights are much impaired).

So, on the one hand, I sense my self doing really good work. Yet, on the other hand . . . the PD expressed "Concern" --and "Concern" is really the actual term used--so vague and non-committal. Furthermore He didn't even talk to me directly. He sank the Chief on me. This put the chief in an awkward position, as he was using third and fourth-hand information. Anyways, why don't I just tell you about an example of the good work first and we can get back to this whole "Concerns" bs.

Here the whole case example: This guy. . . we will call him "C". C came in completely angry and yelling and screaming. He was brought in by the court deputies. C's mother had been concerned that C might be in danger of being kicked out of his residence. So the court well-check people went out there and lied to him by telling him that they were only going to take a ride to the pharmacy to pick up some meds. This was a calculated lie. They lied to him so that he'd be brought into the inpatient unit on a 72 hour hold (we call them 5150 holds in CA).

He became enraged, as I think we all would have been--if we had been deceived, especially if we thought we were losing our freedom, being held against our will. In any case, a Code Grey was called at psych triage. I ran to the Psych ER and saw the patient. (I am not even on the psych ER rotation--my rotation was on the inpatient unit). In any case, I was glad I attended the Code Grey. I had a chance to talk to C from the first moment on. He was inconsolable. So, emergency IM injections for C had to be written.

He then was transferred to my inpatient unit. Throughout the days, I have worked hard him. He can be an angry and intimidating big guy. None-the-less, I worked firmly and directly with him. I acknowledged all the facts--ie that he had been lied to, etc. But, I also directed him and moved him forward.

I really have a soft spot in my heart for my patients and my most important objective with C was that he hold on to his apartment. I told him about my past success stories with ppl who went on the monthly shot. I told him about one particular Big Angry Looking schizophrenic pt I had who always came in to my outpt clinic with that paranoid angry stare. I told C, that I was able to administer monthly shots to this guy and the guy actually held a landscaping job long enough that he was able to purchase a truck (F-150) for himself, which he drove and parked right in front of the clinic to show the staff 🙂. [incidentally, the F-150 is valued at exactly $1999.99 when reported to the DMV. This was done so he would not lose his SSI benefits.]

Anyways, by telling him this story, he agreed to sign a consent for oral risperdal. I had the goal of transitioning him to Invega Sustenna as a monthly shot. Alas, however, he did not want to go on the shot--terrible needle phobia. So, I had to move on and explore the other areas of my plan--which is to address his oral med failure. It turns out that for months and maybe even years, he and his mother had been trying to tell their outpt psych that the med was waaaayyy too strong. There were times when mom took C cloth-shopping at the Thrift store, and C could not even stand up straight. I was able to find out this information by getting mom on the phone with C sitting in front of me. It was very important to have C in front of me when I made the phone call. This way, all information could be cross confirmed. In this way, I gained the trust of my patient. I gave him a low oral dose of risperdal of 2mg po qAM and 3mg HS.

In that phone call, I also explored the reasons why mom initially had that concern that C might eventually be evicted out of his apartment. C had been very vague and evasive about his living situation. But, I felt that my job was very clear. It was to give C the insights to know which behaviors are not socially acceptable. I needed mom on the phone because C really had very little insight. And I also told him that because he hadn't been able to give me a coherent, it meant that he didn't understand his actions. Hence, I was not going to release him from his involuntary hold until we got complete insight into what exact behaviors were getting him so much trouble socially.

Mom was extremely helpful in this regard. It turns out that C has been inside his apartment at night (2 or 3 AM) screaming at the top of his lungs, disturbing his neighbors and being very scary to the neighbors who hear his rampages. He had already received a citation. So, with this information, C finally came clean and told me the details of his true symptoms. He hears God at night. God tells him to masturbate. And he does not want to masturbate. He sees his semen as very precious and cannot bear seeing it spill out, going to waste. He sees that as a draining of his bodily energies. So, he screams at God because God is not helping him to stop masturbating. Also, the screaming is an attempt to not hear the voices. This was a huge break through!!!! I don't believe that he has ever ever told anybody that information. He was quite embarrassed when he told me this story. But, I have gained C's trust.

I then asked him about the risperdal which I gave him. I asked him if it helped him to not think about girls. He answered in the affirmative. So, not only did it help him stop the voices, it also helped him to sleep through the night, instead of being tormented by the voices at 2 am or 3 am all through the night. Furthermore, the right dose also meant that he was able to function during the day.

Today, I plan to continue to work on him to see if he would agree to go on Invega Sustenna monthly.

This has been a very labor intensive case, but MAN! I tell you . . . the pay off has been sooooo gratifying. I am sooooo gratified by the result of this case. This Is EXACTLY WHY I AM A psychiatrists. I believe I have a gift. And I am going to be damn if I let some PD destroy that confidence by raising these Vague aasss "Concerns." The truth is that he does not know me and have not worked with me closely.

Let me just add that when I finished the phone call with mom, she specifically stopped me and said "Dr. T . . . " I said "yes?" . . . . She said " Thank you. Thank you for calling me and taking care of C". I get a little choked up even right now when I think back on those words. This is exactly why I go the extra mile for my patients. I am caring for pts who otherwise had no one to hear them. God knows they have tried to tell people (including their doctors) their problems, but no one has heard. I respect my patients and I hold to the belief that my patients will tell me what they need if I take the time to cut through the pathology and take the time to show them respect. That is my "technique" of reaching my patients.



----

So, now back to the beginning of the my post. The word from the top, which is then relayed to me via the chief, is that "They (i.e. the program)" have concerns about me academically. What they mean is that when I was pimped on several occasions, I was all tongue and could not come up with clean "textbook" answers. So, throughout the Chief, I find out that the PD thinks that I am doing terribly academically. I was initially very devastated by this. Then, I thought back. I realized that the few pimpers have all been people who have not worked closely with me. So, I went back to the attendings with whom I did work closely. They all tell me that I am doing just fine. They see the hard work which I am doing and the extra mile that I go for my patients. They also tell me that they have no problems (or "Concerns") with my clinical acumen, nor my abilities as a competent physician and a psychiatrist. They have also agreed to advocate for me to the top and clear up this whole mess.

So, the moral of the story is that you have to do what you know how to do and go with your strength. A certain number of people will "get" you (i.e. the attendings who know me well; and all the nursing staff and Social workers--they "get" me and love being with me). Then, there are going to be a few people (in this case, the few attendings who just do coverage shifts) who are not going to understand you. And these few are the ones that raise "Concerns". That is always how these things work. And you just can't let them destroy you. You have to trust in your own ability enough. Go get feedback from people who know your work and regain that self-respect and fearless confidence which makes you the damn good doctor that you know you are. And, which you strive to add to, daily.

thank you for reading. Please if any words of comment or thoughts will be appreciated. I am still somewhat recovering from the injury to my psyche from the whole "We have Concerns about you" debacle.

Sincerely, signed: recovering.

Resident extraordinaire [sic], Dr. T

 

[ShrunkenHeads]

Thanks for sharing that wonderful story and congrats on breaking through with the patient! I don't know any other details about you, but that right there is a good example of someone who has chosen a field that suits them.

It really sucks hearing "concerns" about yourself from an authoritative figure, but you did the right thing to find out where it stemmed from. That's exactly what I would have done in your situation.

Moral of the story, always consider the source.

 

[heyjack70]

1st thing is, are they telling you there are concerns so you will study more? That's a pretty harmless suggestion. I think it's easy to hear a comment like you described and start jumping to conclusions about being remediated, fired, etc when all they were trying to convey was you should be reading more.

 

[whopper]

I got a mediocre review during my first rotation. What was going on in reality was I didn't know what was going on, was in an emergency psychiatric unit, and the attending wasn't teaching me and frustrated that I didn't know what was going on......because he wasn't teaching me.

At that time, I had mixed feelings about it. I didn't think I was doing a great job, but I was doing the best job I could. I wasn't given appropriate direction but didn't know about it at that time, but I did know that I was doing everything in my power to do a good job.

By the time I graduated, it turned out my reviews were a heck of a lot better than his as a resident and he was a graduate of the program. I knew this because as a chief, I was told of this guy's mediocre performance by the dept. head, and they told me they had problems with him as a resident, and he would be the first guy to complain so he could work less but he tried to get residents to do all his work for him. I could also tell that by my 3rd and fouth year, I was actually a better doctor than that other guy. I only had two reviews that were less than excellent, one from this guy, and one from a guy that pretty much was practicing less than honorably.

The program kept the guy because of the shortage of psychiatrists and because he was smart enough to fall-in-line with the dept head when she made requests. (Hey at least he did that compared to another guy I mentioned in another thread who only showed up about 15 minutes a day, signed notes, and left and openly violated requests she made).

A lot of the validity of an evaluation depends on the evaluator. If you're brand new as a resident, expect to not do so hot when you're green. Do your best. Is the evaluation fair? I don't know because I don't know you well or the evaluator.

As for your PD, he should make himself available to you. Maybe he can't see you daily (and I wouldn't expect him to do so), but at least on an order of once-in-awhile. Information should be transferred to you in a manner better than third hand.

 

[atsai3]

Guys: I am being told by the Chief resident that "They" the top (i.e. the program director) has concerns about me academically.

At first this was very devastating. I mean I had always thought that I was doing pretty well. It isn't me just being grandiose--I reality checked myself--I am reaching patients; I am getting through to very difficult patients about their med compliance. I work extra hours trying to talk to both the patient and the families so that there is a coherent story. This is especially important when schizophrenic patients have no clue why they are about to be kicked out of their apartment (i.e. their insights are much impaired).

So, on the one hand, I sense my self doing really good work. Yet, on the other hand . . . the PD expressed "Concern" --and "Concern" is really the actual term used--so vague and non-committal. Furthermore He didn't even talk to me directly. He sank the Chief on me. This put the chief in an awkward position, as he was using third and fourth-hand information. Anyways, why don't I just tell you about an example of the good work first and we can get back to this whole "Concerns" bs.

Here the whole case example: This guy. . . we will call him "C". C came in completely angry and yelling and screaming. He was brought in by the court deputies. C's mother had been concerned that C might be in danger of being kicked out of his residence. So the court well-check people went out there and lied to him by telling him that they were only going to take a ride to the pharmacy to pick up some meds. This was a calculated lie. They lied to him so that he'd be brought into the inpatient unit on a 72 hour hold (we call them 5150 holds in CA).

He became enraged, as I think we all would have been--if we had been deceived, especially if we thought we were losing our freedom, being held against our will. In any case, a Code Grey was called at psych triage. I ran to the Psych ER and saw the patient. (I am not even on the psych ER rotation--my rotation was on the inpatient unit). In any case, I was glad I attended the Code Grey. I had a chance to talk to C from the first moment on. He was inconsolable. So, emergency IM injections for C had to be written.

He then was transferred to my inpatient unit. Throughout the days, I have worked hard him. He can be an angry and intimidating big guy. None-the-less, I worked firmly and directly with him. I acknowledged all the facts--ie that he had been lied to, etc. But, I also directed him and moved him forward.

I really have a soft spot in my heart for my patients and my most important objective with C was that he hold on to his apartment. I told him about my past success stories with ppl who went on the monthly shot. I told him about one particular Big Angry Looking schizophrenic pt I had who always came in to my outpt clinic with that paranoid angry stare. I told C, that I was able to administer monthly shots to this guy and the guy actually held a landscaping job long enough that he was able to purchase a truck (F-150) for himself, which he drove and parked right in front of the clinic to show the staff 🙂. [incidentally, the F-150 is valued at exactly $1999.99 when reported to the DMV. This was done so he would not lose his SSI benefits.]

Anyways, by telling him this story, he agreed to sign a consent for oral risperdal. I had the goal of transitioning him to Invega Sustenna as a monthly shot. Alas, however, he did not want to go on the shot--terrible needle phobia. So, I had to move on and explore the other areas of my plan--which is to address his oral med failure. It turns out that for months and maybe even years, he and his mother had been trying to tell their outpt psych that the med was waaaayyy too strong. There were times when mom took C cloth-shopping at the Thrift store, and C could not even stand up straight. I was able to find out this information by getting mom on the phone with C sitting in front of me. It was very important to have C in front of me when I made the phone call. This way, all information could be cross confirmed. In this way, I gained the trust of my patient. I gave him a low oral dose of risperdal of 2mg po qAM and 3mg HS.

In that phone call, I also explored the reasons why mom initially had that concern that C might eventually be evicted out of his apartment. C had been very vague and evasive about his living situation. But, I felt that my job was very clear. It was to give C the insights to know which behaviors are not socially acceptable. I needed mom on the phone because C really had very little insight. And I also told him that because he hadn't been able to give me a coherent, it meant that he didn't understand his actions. Hence, I was not going to release him from his involuntary hold until we got complete insight into what exact behaviors were getting him so much trouble socially.

Mom was extremely helpful in this regard. It turns out that C has been inside his apartment at night (2 or 3 AM) screaming at the top of his lungs, disturbing his neighbors and being very scary to the neighbors who hear his rampages. He had already received a citation. So, with this information, C finally came clean and told me the details of his true symptoms. He hears God at night. God tells him to masturbate. And he does not want to masturbate. He sees his semen as very precious and cannot bear seeing it spill out, going to waste. He sees that as a draining of his bodily energies. So, he screams at God because God is not helping him to stop masturbating. Also, the screaming is an attempt to not hear the voices. This was a huge break through!!!! I don't believe that he has ever ever told anybody that information. He was quite embarrassed when he told me this story. But, I have gained C's trust.

I then asked him about the risperdal which I gave him. I asked him if it helped him to not think about girls. He answered in the affirmative. So, not only did it help him stop the voices, it also helped him to sleep through the night, instead of being tormented by the voices at 2 am or 3 am all through the night. Furthermore, the right dose also meant that he was able to function during the day.

Today, I plan to continue to work on him to see if he would agree to go on Invega Sustenna monthly.

This has been a very labor intensive case, but MAN! I tell you . . . the pay off has been sooooo gratifying. I am sooooo gratified by the result of this case. This Is EXACTLY WHY I AM A psychiatrists. I believe I have a gift. And I am going to be damn if I let some PD destroy that confidence by raising these Vague aasss "Concerns." The truth is that he does not know me and have not worked with me closely.

Let me just add that when I finished the phone call with mom, she specifically stopped me and said "Dr. T . . . " I said "yes?" . . . . She said " Thank you. Thank you for calling me and taking care of C". I get a little choked up even right now when I think back on those words. This is exactly why I go the extra mile for my patients. I am caring for pts who otherwise had no one to hear them. God knows they have tried to tell people (including their doctors) their problems, but no one has heard. I respect my patients and I hold to the belief that my patients will tell me what they need if I take the time to cut through the pathology and take the time to show them respect. That is my "technique" of reaching my patients.



----

So, now back to the beginning of the my post. The word from the top, which is then relayed to me via the chief, is that "They (i.e. the program)" have concerns about me academically. What they mean is that when I was pimped on several occasions, I was all tongue and could not come up with clean "textbook" answers. So, throughout the Chief, I find out that the PD thinks that I am doing terribly academically. I was initially very devastated by this. Then, I thought back. I realized that the few pimpers have all been people who have not worked closely with me. So, I went back to the attendings with whom I did work closely. They all tell me that I am doing just fine. They see the hard work which I am doing and the extra mile that I go for my patients. They also tell me that they have no problems (or "Concerns") with my clinical acumen, nor my abilities as a competent physician and a psychiatrist. They have also agreed to advocate for me to the top and clear up this whole mess.

So, the moral of the story is that you have to do what you know how to do and go with your strength. A certain number of people will "get" you (i.e. the attendings who know me well; and all the nursing staff and Social workers--they "get" me and love being with me). Then, there are going to be a few people (in this case, the few attendings who just do coverage shifts) who are not going to understand you. And these few are the ones that raise "Concerns". That is always how these things work. And you just can't let them destroy you. You have to trust in your own ability enough. Go get feedback from people who know your work and regain that self-respect and fearless confidence which makes you the damn good doctor that you know you are. And, which you strive to add to, daily.

thank you for reading. Please if any words of comment or thoughts will be appreciated. I am still somewhat recovering from the injury to my psyche from the whole "We have Concerns about you" debacle.

Sincerely, signed: recovering.

Resident extraordinaire [sic], Dr. T

In my experience, remediation, non-renewal, firing, etc. are not approached lightly or arbitrarily. So if your PD (through your chief) is trying to warn you about those potential outcomes, I do think you should pay heed to the (however evasively delivered) warning. It may be worth scheduling a meeting with your PD or your attendings (the ones with whom you have not worked closely) to obtain specific feedback about specific criticisms that you can remedy. If, in the end, the true story is really just the "I missed a few pimp questions but really I'm a good clinician, these arrogant attendings just can't see me for who I really am" tale of woe, then taking this incident seriously and doing a little digging hasn't hurt you at all. But if you really do have a blind spot and are headed for some sort of bad outcome, then brushing this off as "they just don't understand me" is probably about the worst thing you can do for yourself.

 

[nitemagi]

+1 Atsai's response.

If you're a PGY-1 they may also be attempting to test to see how much you can improve when they give you feedback. Presuming you're a PGY-1 they may also be reading heavily into fewer datapoints, which will wash out over time. But I agree with Atsai I wouldn't blow this off.

 

[masterofmonkeys]

In my experience, remediation, non-renewal, firing, etc. are not approached lightly or arbitrarily.

Yeah, I'm a bit bitter, but...Hi Dr. Pangloss, how are you?

 

[psychattending]

I would concur with what atsai3 wrote. Two additional comments: 1) I will often make use of my chief resident to initially talk with a resident who is having a significant problem. Residents usually do not feel as threatened with this approach and feel more open about talking/working with another resident to fix a problem. 2) Also I much prefer addressing issues this way if they can be handled this way. Once I get involved formally as the program director then I have to document things. Licensing agencies like asking questions like: did the resident have any documented problems. If a resident can fix the issue unofficially, then I don't have to inform outside people.

 

[notdeadyet]

Yeah, I'm a bit bitter, but...Hi Dr. Pangloss, how are you?

No, I reckon atsai3's right. It's a lot easier for a program and PD to either work on mentoring/coaching/treating (or even just floating deadweight) than it is to outright dismiss someone.

Maybe truly malignant programs are different, but the one's I've been in contact haven't gotten rid of people without a lot leading up to it.

You seem like a sharp guy, MoM, based on past posts (and the fact that no one who drops Voltaire lived life without picking up a book). But I can't help but wonder if your experiences are maybe way outside the norm.

 

[peiyueng]

I would concur with what atsai3 wrote. Two additional comments: 1) I will often make use of my chief resident to initially talk with a resident who is having a significant problem. Residents usually do not feel as threatened with this approach and feel more open about talking/working with another resident to fix a problem. 2) Also I much prefer addressing issues this way if they can be handled this way. Once I get involved formally as the program director then I have to document things. Licensing agencies like asking questions like: did the resident have any documented problems. If a resident can fix the issue unofficially, then I don't have to inform outside people.

Thank you every one. Great advise from everyone. I will not take this lightly. I will find out more info from the open door that belong to the pd and the assistant pd. I am working as an upper year res. I came into the res as an upper year. I am currently rotating with the 2nd in charge program head and he is very pleased with my initiative and my work with pts. But I will continue to gain more insights and info into this, as I am not going to take this lightly. Finishing this res is very impt to me. Because there is a lot of good work ahead of me and a lot of lives that I will touch and get touched by. So I am not going to take anything for granted thx!

 

[IAmAUser]

.

 

[notdeadyet]

I am working as an upper year res. I came into the res as an upper year.

This is probably a significant piece of information. If you transferred in as an upper year, you're going to probably be under more scrutiny than your peers. Even if you transferred in for reasons that had nothing to do with your performance or relationships at your last residency, you're less of a known entity and will therefore probably be looked at a little more closely than others.

 

[peiyueng]

agree with advice above, but my additional .02 to OP, I would really not post such specific details about patients on a public forum. that could cause problems for both you and the pt in the future.
good luck though..

Sounds like you were also at that recent Psychiatry and Technology conference put on by the APA and the SCPS. These are new problems that have come up with electronic and social media. The morales and rules of engagement in social media have not solidified themselves. On the one hand, we are a think tank. On the other hand, all facts to the case had to be completely modified in order to protect the parties so that they are anonymous. They are so altered that they are more different than fiction. So, let's just say that all the information has been carefully altered to a parallel but equivalent situation. For example, instead of living in a apartment, the guy lives in a back room house. And instead of masturbating to girls, he masturbates to guys. And instead of yelling at God, he yells at Aliens.

All facts have been carefully altered so that there is no way to truly identify the parties involved. This is the way that social media must be approached, if we ever want to talk about specific cases.

cheers.

 

[michaelrack]

I would encourage the OP to be very careful, since he has identified his residency program in other threads.

Perhaps the PD is concerned about his PRITE score (which he identified in another thread that he was taking in October)???

 

[whopper]

Agree with the above. A transfer as an upper year, with mention of concerns from the PD is a worse sign than a lower year. Definitely take what has happened as an opportunity to figure out what's going on and what you may improve upon, assuming the evaluation was fair.

 

[billypilgrim37]

Agreed. I certainly wouldn't presume to say that your assessment of yourself isn't accurate, but the things you're saying sound EXACTLY like the ways that our worst resident rationalized the feedback she received. Sometimes word for word. I do think the program went out of their way to try to bring her up to at least a minimal level of competency to graduate her, but as her colleague, I think she should have been fired sometime after second year.

So, you may have been targeted unfairly, but that's a pretty all-or-none sort of thought. Some of the feedback may be unfair, but your program may also be trying to help you make up for some deficiencies that you're blind to. People you've worked with closely and who may like you personally may not feel comfortable giving you honest criticism.

 

[atsai3]

Another thing is that, from the perspective of the person giving the feedback, very critical feedback can be difficult to give. Unless the person is an outright !@W#%$!@#$, then she will have a natural tendency to want to soften the blow a little bit. So it is very possible that "we have concerns" and "you weren't able to answer some pimp questions correctly" is simply the tip of the iceberg, and that the OP will need to dig harder, and ask directly for unvarnished, candid feedback (which is hard to do, from the perspective of the person receiving the feedback).

 

[peiyueng]

I would encourage the OP to be very careful, since he has identified his residency program in other threads.

Perhaps the PD is concerned about his PRITE score (which he identified in another thread that he was taking in October)???

Yep I did take prite. Results come out dec. So that will b definitive objective measure that cannot b soft washed. So I welcome prite results. I hav always been a good test taker. This time around, I didn't hav much time to study. Hence, I may or may not have done above or below average. But in any case, I will wait for prite results.

What I mean is that if prite shows that there r areas I need to improve, I will simply study my ass off and it will no longer b an issue next year.

I don't know the results of this past oct prite yet, but I am expecting to hav done just about average. Since I didn't get much time to prep, I am not expecting to be in the elites. But I did study enough and am a gd enough test taker to probably hav dOne near or close to avg.

What I am realizing from reading one of the posts in these replies is that patient care results don't mean **** because even ppl who should b fired can say the same sort of things that I had said in the original post ( one replier said that one lady said some things word for word the way I was saying them). So that tells me that that type of defense don't mean shiit if a pd wants to hav obj measure. So that is why I am going to start gathering objective measures and put more wt on concrete measures. It is kind of unfortunate that my true gift as a caring doc can't be measured because imposters (ie that woman that should have been fired) can steal the same words that I use to describe myself. But i am a big boy and I understand that this is just the reality of life. So, I am going to go forth carefully and give those pd type folks the objective measures that they so lazily need. Prite scores are certainly easier for pd's to figure out than trying to figure out if someone is a good doctor. So I am mature enough to comply -and just make it simple and straight cut for all involved.

Thx again for all the great words of wisdom

Cheers

Bottom line: once prite results come out, I will either shut them up, or have handed them real objective ammunition 2 hav "concerns". In either case, I plan to study my aass off and make that no longer a concern. Problem solved.

 

[cleareyedguy]

What I am realizing from reading one of the posts in these replies is that patient care results don't mean **** because even ppl who should b fired can say the same sort of things that I had said in the original post ( one replier said that one lady said some things word for word the way I was saying them). So that tells me that that type of defense don't mean shiit if a pd wants to hav obj measure. So that is why I am going to start gathering objective measures and put more wt on concrete measures. It is kind of unfortunate that my true gift as a caring doc can't be measured because imposters (ie that woman that should have been fired) can steal the same words that I use to describe myself. ...

Bottom line: once prite results come out, I will either shut them up, or have handed them real objective ammunition 2 hav "concerns". In either case, I plan to study my aass off and make that no longer a concern. Problem solved.

These are worrisome responses and indicate--to my mind-- a simplistic and immature response to a lot of good advice. You do need to learn more psychiatry and more about psychiatry. You also need to not go into so much detail about a patient, and if you really did disguise the pt, you need to clarify that up front. Finally, if you do something out of the ordinary (eg, are you supposed to participate in the ED's handling of a patient when you are on the inpt unit? did you collude through action or a complicit smile when the patient bought a car and lied to the government about its value in order to get benefits?), you really do need to be aware of it.

 

[notdeadyet]

What I am realizing from reading one of the posts in these replies is that patient care results don't mean **** because even ppl who should b fired can say the same sort of things that I had said in the original post ( one replier said that one lady said some things word for word the way I was saying them). So that tells me that that type of defense don't mean shiit if a pd wants to hav obj measure. So that is why I am going to start gathering objective measures and put more wt on concrete measures.

I'm with cleareyedguy in being a little concerned about the tack you're taking with your response.

In the face of criticism, it's probably wisest (from a learning and professionalism perspective) to look at the areas that are being judged as needing improvement. If you disagree with the critic's perspective, it's healthy to respond back to the critic asking for clarification and ask for specific recommendations for areas of improvement. Entering a dialogue is a good thing and would probably be welcome.

The approach you seem to be taking is figuring out ways to prove yourself by bypassing the areas you're being criticized about. Focusing on the PRITE is great if you're being criticized about your PRITE results. But if the criticism is indeed about how you articulate your fund of knowledge verbally, it's probably wisest to figure out how to improve that. Ignoring it and pointing elsewhere as evidence of your worth might not have the effect you're hoping for and might be counterproductive.

Just a thought. I hope you're able to resolve the issues with your department. But being a late transfer to a program and being viewed as struggling (by at least some people), you might find you get what you want better through cooperation instead of divide-and-conquer.

 

[ghost dog]

Guys: I am being told by the Chief resident that "They" the top (i.e. the program director) has concerns about me academically.

At first this was very devastating. I mean I had always thought that I was doing pretty well. It isn't me just being grandiose--I reality checked myself--I am reaching patients; I am getting through to very difficult patients about their med compliance. I work extra hours trying to talk to both the patient and the families so that there is a coherent story. This is especially important when schizophrenic patients have no clue why they are about to be kicked out of their apartment (i.e. their insights are much impaired).

So, on the one hand, I sense my self doing really good work. Yet, on the other hand . . . the PD expressed "Concern" --and "Concern" is really the actual term used--so vague and non-committal. Furthermore He didn't even talk to me directly. He sank the Chief on me. This put the chief in an awkward position, as he was using third and fourth-hand information. Anyways, why don't I just tell you about an example of the good work first and we can get back to this whole "Concerns" bs.

Here the whole case example: This guy. . . we will call him "C". C came in completely angry and yelling and screaming. He was brought in by the court deputies. C's mother had been concerned that C might be in danger of being kicked out of his residence. So the court well-check people went out there and lied to him by telling him that they were only going to take a ride to the pharmacy to pick up some meds. This was a calculated lie. They lied to him so that he'd be brought into the inpatient unit on a 72 hour hold (we call them 5150 holds in CA).

He became enraged, as I think we all would have been--if we had been deceived, especially if we thought we were losing our freedom, being held against our will. In any case, a Code Grey was called at psych triage. I ran to the Psych ER and saw the patient. (I am not even on the psych ER rotation--my rotation was on the inpatient unit). In any case, I was glad I attended the Code Grey. I had a chance to talk to C from the first moment on. He was inconsolable. So, emergency IM injections for C had to be written.

He then was transferred to my inpatient unit. Throughout the days, I have worked hard him. He can be an angry and intimidating big guy. None-the-less, I worked firmly and directly with him. I acknowledged all the facts--ie that he had been lied to, etc. But, I also directed him and moved him forward.

I really have a soft spot in my heart for my patients and my most important objective with C was that he hold on to his apartment. I told him about my past success stories with ppl who went on the monthly shot. I told him about one particular Big Angry Looking schizophrenic pt I had who always came in to my outpt clinic with that paranoid angry stare. I told C, that I was able to administer monthly shots to this guy and the guy actually held a landscaping job long enough that he was able to purchase a truck (F-150) for himself, which he drove and parked right in front of the clinic to show the staff 🙂. [incidentally, the F-150 is valued at exactly $1999.99 when reported to the DMV. This was done so he would not lose his SSI benefits.]

Anyways, by telling him this story, he agreed to sign a consent for oral risperdal. I had the goal of transitioning him to Invega Sustenna as a monthly shot. Alas, however, he did not want to go on the shot--terrible needle phobia. So, I had to move on and explore the other areas of my plan--which is to address his oral med failure. It turns out that for months and maybe even years, he and his mother had been trying to tell their outpt psych that the med was waaaayyy too strong. There were times when mom took C cloth-shopping at the Thrift store, and C could not even stand up straight. I was able to find out this information by getting mom on the phone with C sitting in front of me. It was very important to have C in front of me when I made the phone call. This way, all information could be cross confirmed. In this way, I gained the trust of my patient. I gave him a low oral dose of risperdal of 2mg po qAM and 3mg HS.

In that phone call, I also explored the reasons why mom initially had that concern that C might eventually be evicted out of his apartment. C had been very vague and evasive about his living situation. But, I felt that my job was very clear. It was to give C the insights to know which behaviors are not socially acceptable. I needed mom on the phone because C really had very little insight. And I also told him that because he hadn't been able to give me a coherent, it meant that he didn't understand his actions. Hence, I was not going to release him from his involuntary hold until we got complete insight into what exact behaviors were getting him so much trouble socially.

Mom was extremely helpful in this regard. It turns out that C has been inside his apartment at night (2 or 3 AM) screaming at the top of his lungs, disturbing his neighbors and being very scary to the neighbors who hear his rampages. He had already received a citation. So, with this information, C finally came clean and told me the details of his true symptoms. He hears God at night. God tells him to masturbate. And he does not want to masturbate. He sees his semen as very precious and cannot bear seeing it spill out, going to waste. He sees that as a draining of his bodily energies. So, he screams at God because God is not helping him to stop masturbating. Also, the screaming is an attempt to not hear the voices. This was a huge break through!!!! I don't believe that he has ever ever told anybody that information. He was quite embarrassed when he told me this story. But, I have gained C's trust.

I then asked him about the risperdal which I gave him. I asked him if it helped him to not think about girls. He answered in the affirmative. So, not only did it help him stop the voices, it also helped him to sleep through the night, instead of being tormented by the voices at 2 am or 3 am all through the night. Furthermore, the right dose also meant that he was able to function during the day.

Today, I plan to continue to work on him to see if he would agree to go on Invega Sustenna monthly.

This has been a very labor intensive case, but MAN! I tell you . . . the pay off has been sooooo gratifying. I am sooooo gratified by the result of this case. This Is EXACTLY WHY I AM A psychiatrists. I believe I have a gift. And I am going to be damn if I let some PD destroy that confidence by raising these Vague aasss "Concerns." The truth is that he does not know me and have not worked with me closely.

Let me just add that when I finished the phone call with mom, she specifically stopped me and said "Dr. T . . . " I said "yes?" . . . . She said " Thank you. Thank you for calling me and taking care of C". I get a little choked up even right now when I think back on those words. This is exactly why I go the extra mile for my patients. I am caring for pts who otherwise had no one to hear them. God knows they have tried to tell people (including their doctors) their problems, but no one has heard. I respect my patients and I hold to the belief that my patients will tell me what they need if I take the time to cut through the pathology and take the time to show them respect. That is my "technique" of reaching my patients.



----

So, now back to the beginning of the my post. The word from the top, which is then relayed to me via the chief, is that "They (i.e. the program)" have concerns about me academically. What they mean is that when I was pimped on several occasions, I was all tongue and could not come up with clean "textbook" answers. So, throughout the Chief, I find out that the PD thinks that I am doing terribly academically. I was initially very devastated by this. Then, I thought back. I realized that the few pimpers have all been people who have not worked closely with me. So, I went back to the attendings with whom I did work closely. They all tell me that I am doing just fine. They see the hard work which I am doing and the extra mile that I go for my patients. They also tell me that they have no problems (or "Concerns") with my clinical acumen, nor my abilities as a competent physician and a psychiatrist. They have also agreed to advocate for me to the top and clear up this whole mess.

So, the moral of the story is that you have to do what you know how to do and go with your strength. A certain number of people will "get" you (i.e. the attendings who know me well; and all the nursing staff and Social workers--they "get" me and love being with me). Then, there are going to be a few people (in this case, the few attendings who just do coverage shifts) who are not going to understand you. And these few are the ones that raise "Concerns". That is always how these things work. And you just can't let them destroy you. You have to trust in your own ability enough. Go get feedback from people who know your work and regain that self-respect and fearless confidence which makes you the damn good doctor that you know you are. And, which you strive to add to, daily.

thank you for reading. Please if any words of comment or thoughts will be appreciated. I am still somewhat recovering from the injury to my psyche from the whole "We have Concerns about you" debacle.

Sincerely, signed: recovering.

Resident extraordinaire [sic], Dr. T

Hi there,

I'm not in Psychiatry but I do a lot of teaching in medicine.

In regards to this feedback you received was it in written format? If it wasn't, you might want to ask the Chief to provide you with such feedback (purely for your own learning objectives) so you can try in improve in the areas identifed that need work. Once they have done so, I would ask for a follow up appointment in 2-3 months for a reassessment to get an idea of how you are doing. You might want to ask for a mentor if you don't have one.

During this period, I think it would be a good idea to really focus on the areas that have been mentioned.

Taking such a pro-active approach shows the program director that you are attempting to rectify the identified weaknesses. At the very least, you have shown some initiative.

 

[peiyueng]

My fund of knowledge is lacking in terms of being able to verbalize them. I have a lack of fund of knowledge in the eyes of at least one attending. I need to work on my fund of knowledge. I need to practice reciting knowledge cleanly and concisely. I used to do that as a medical student. Back then, I practiced some slick recitations on a few select topics. When opportunities arose for me to show off my knowledge, I would rattle off long strings of words and paragraphs all in one breath. It gave me the appearance of having encyclopedic knowledge. And it was fun. This type of showmanship (for the lack of a better word) made both my wife and myself really stand out during or IM rotations. So, I think it is time I called upon that skill once again and target a few topics that I can recite efficiently and with depth.

Another problem I currently have is that I have a lack of ability to present cases in a ordered fashion. I , at times, have been jumping around like a mother fuker when presenting. So, I have already improved on that: i.e. HPI has to start like this:

HPI: X is a 31 y/o homeless AAF BIB PD 5150 for standing in the middle of the street with her pants down to ankles. Per PD report, she was combative, evasive with questions and unable to demonstrate ability to care for self. [AAF= black female; BIB = brought in by; PD = Police Dept; 5150 = 72 hr hold]

Then, from there, I need to go into past psych history (most of the time, it is base on past medical records which we call SIMON). So, I would say something like patient has a long history of mental illness with SIMON going back to 2002, containing over 100 episodes, including long history of subtance abuse, . etc, etc, etc.


By going with the above templates way of presenting, I have already made headway with one of the attendings that was specifically named by my Chief. In other words, the chief specially dropped this Attending's name. So, I have been soliciting this guy's feedback. He told me that I have tended to be disorganized in my presentation. So, I have fixed that part. But, as mentioned above, I still need to fix the part where he pimps me and I don't have full, clean, answers. That part remains to be fixed. But, at the very least, now when I present to him, he says that my presentations are good. So, I am happy about that.



As far as mentioning the PRITE. . . . a little back story: My PD has explicitly said that PRITE is impt. The previous two grads from our program scored 90+ percentile on their boards. He jokingly says that we are all expected to do the same ;-). But, all joking has truth in it. So, PRITE is important. I plan to do at least average which, while not impressive, is at least going to illustrate that I am not falling behind. December is the release date of the prite scores.


One poster earlier asked about my actions of rushing to the Psych ER all-the-while with my being on an inpt rotation. Well, in our program, running to Code Grays is not only a good thing, but it is actually expected. Code Grays are the psych equivalent of Code Blues. All residents are expected to run to codes. However, it is more often the case that they run away from the codes rather than towards them. I love what I do and I not only run to code grays, but if I am nearby, I run to the code blues as well. Just yesterday, I ran to the fifth floor on a de-sat and was able to assist in an thoracentesis where nearly 2 liters of serous fluid was tapped from this one lady who is a 56 year old hispanic female with suspected CA. Granted, I didn't get to do much, but I was able to hold the patient still in a sitting position (a very awkward position as this was done emergently on her bed). I held the sterile drape in place while I steadied her in the sitting position, letting her brace herself against me. She was in quite a bit of pain as the tap proceeded. I braced her still while calmly explaining each step of the way: i.e. "Little poke . . . you are going to feel Some pressure and burning . . . They are injecting you with some numbing medication. Hang in there . . . . You are going to be able to breath much better after this." etc etc. She started coughing after about 2 liters and they had to stop the tap because apparently pulmonary edema is a concern if more than that amount is taken out of a patient. So, I learned something on that code ;-).

Isn't being a doctor just grand? I am loving it! Of course, it isn't without its shiitty parts. I mean, at times it can be really shiity--such as when you receive third hand information that "they" (i.e. the PD) have "concerns." But, I am going to just keep on doing what I love doing while addressing each of those "concerns," as I discover what they are.

I know some of my posts don't make me sound "professional." But, hey. I like cussing and talking shiit. Cussing and talking shiit breathes life into the language. I kind of love it. I cuss and talk shiit all the time. And if it makes the up-tight mother fukers uncomfortable--all the better. By the way, the attending under whom I am currently rotating on the Inpt unit is the assistant PD. And he cusses like you can't believe. He cusses more than any professional I have ever met! So, I am in good company. LOL. ****ing awesome! For those who don't get it, . . . . well, as the Brits say: "Fuk'em, Fuk the whole lot of 'em.!" Yeah!

I realize that this last paragraph makes me less than a sympathetic character; but hey, I don't know, I am forty years old and I have learned that sympathy only gets you so far in life. I am rambling now, so I will shut the fuk up.



So long for now; and Thanks for all the Fish!

Signed: Kicking Ass and Taking Names.

 

[peiyueng]

Hi there,



Taking such a pro-active approach shows the program director that you are attempting to rectify the identified weaknesses. At the very least, you have shown some initiative.

Yeah. I am going to be pro-active. That is good advice. I love my residency too much to let this sit without doing everything within my lazy powers to fix it to the best of my approximate ability. Everyday will be used to work towards this end.

No worries. I will fix this and continue to enjoy all that is soooo great about my residency. It is an awesome residency for sure. I feel very good about it, and love it despite of all that what I have sed that may have given you the wrong impression.

cheers.

 

[nancysinatra]

One poster earlier asked about my actions of rushing to the Psych ER all-the-while with my being on an inpt rotation. Well, in our program, running to Code Grays is not only a good thing, but it is actually expected. Code Grays are the psych equivalent of Code Blues. All residents are expected to run to codes. However, it is more often the case that they run away from the codes rather than towards them. I love what I do and I not only run to code grays, but if I am nearby, I run to the code blues as well. Just yesterday, I ran to the fifth floor on a de-sat and was able to assist in an thoracentesis where nearly 2 liters of serous fluid was tapped from this one lady who is a 56 year old hispanic female with suspected CA. Granted, I didn't get to do much, but I was able to hold the patient still in a sitting position (a very awkward position as this was done emergently on her bed). I held the sterile drape in place while I steadied her in the sitting position, letting her brace herself against me. She was in quite a bit of pain as the tap proceeded. I braced her still while calmly explaining each step of the way: i.e. "Little poke . . . you are going to feel Some pressure and burning . . . They are injecting you with some numbing medication. Hang in there . . . . You are going to be able to breath much better after this." etc etc. She started coughing after about 2 liters and they had to stop the tap because apparently pulmonary edema is a concern if more than that amount is taken out of a patient. So, I learned something on that code ;-).

Why on earth would you attend a code from another service? Aren't you busy on psychiatry? Do you also run to patients' rooms when there is a call on the overhead for anesthesiology to come intubate? In any case, you shouldn't "run" to codes. You should walk quickly. Running in a hospital can be dangerous. Plus I seriously find it hard to believe that any program would actually want its entire psychiatry residency to attend these "code greys." That's just odd. Even on IM, when a code blue is called, not ALL medicine residents attend.

I started out reading this thread and having sympathy for you, but by the end I lost it. You sound as if you think you are way more compassionate and dedicated than everyone else. Don't you think other residents and attendings care about their patients as well? It's just expected that you will be dedicated--it doesn't put you at the top.