Friday, April 06, 2007

We Need to Talk...

Milk & Two Sugars writes in regards to underperforming medical students and interns:

My opinion is this: that most people, when they fail to meet a certain expectation, are unaware that they're doing so. Unless we're told, we can't ever be expected to realise our shortcomings. So why - when an intern or student is lazy, ineffective, or otherwise failing to meet an important expectation - are junior docs reluctant to tell them to pull their socks up?

I must say that there are a few things to point out, M&TS:
  1. Medical Staff in a hospital are like people on an escalator. At some point all of us had to step on, and started at the back, and then we moved up the line. We all remember what it was like being chastised, embarrassed and humiliated by the person in front, rare as those occasions might have been. We don't like doing it to those behind us unless things get really bad, and often by that stage it is a bit too late.
    Maxwell Smart's Cone of Silence
    The only way to have a private conversation in a hospital.
  2. It is unprofessional to criticise a colleague (even a junior is a colleague) in public. Unfortunately, it is rare to find a private moment to have these discussions in a hectic day at the hospital. There is always somebody around - nurses, patients, other doctors.
  3. Often the junior knows what is coming and will actively avoid situations where they have to confront their senior. This may happen deliberately or unconsciously.
  4. Most of us have not had adequate training on how to deal with these situations, teaching modalities, and conflict resolution. Even when you can manage to sit down in private with this person, it is very easy to say the wrong thing, or to get so emotionally wound up about it yourself that you cannot be professional, courteous and objective in your feedback.
  5. Not uncommonly, procrastination on your half may lead to avoidance behaviour by yourself as well. This may take the form of ignoring the problem, completing the tasks yourself, delegating the criticism or feedback to someone else (like a senior), or excusing the junior's behaviour. This may be rationalised away: "It's too hard to change them", "They're untrainable", "It's not worth the trouble", "It's faster if I do it", "It should be the Head of Unit that talks to them", "They've got a lot on their plate" etc.
  6. Lastly, part of the journey is to learn some natural self-awareness. Usually I believe that the junior staff member is aware of their own faults - they just need gentle encouragement to improve their behaviour. Don't underestimate the power of the subtle look of disappointment, or the probing question which shows that both you and they know what the problem is but escapes everyone else. There comes a time when you will not always have someone else to pull you aside and talk to you - you have to keep an eye out for yourself.
There is a bit of an art to apprenticeship-style training. And while the quiet talk in private has its place, one should be judicious about when and how to use it. Unfortunately, most of us are not very good at this side of medicine. Not all of us are born managers, but it is inevitable that at some stage we have to manage someone who is not very good, and those skills come with time and practise.

As for advice for you, M&TS? Be proactive about your training and your faults. Our training system is intended to encourage medical students and HMOs to have enquiring minds, and to seek out answers. Your seniors may know the answers, but not be very good at teaching you. If you sit back and let it all happen to you, then you don't get the full benefit of the opportunities that are available to you.


Milk & Two Sugars said...

Thank you, Sheepish - I appreciate the length and detail of this reply.

Most of them are good reasons; with the exception of being poorly trained in dealing with such situations, I'd considered them all. But I hadn't given them much weight individually until I saw them all together, as you've written them. It seems like they compound to make the entire situation more difficult.

I'm not idealistic; I don't believe there's any perfect method of training and communicating JMO's. But you've put the problems in perspective.

Finally, thanks for the advice, and the trouble you've gone to - it's given me a better understanding.

Sheepish said...

I'm glad you find it useful. Best of luck with your studies.

Anonymous said...

Consider this:
Patient welfare is the most important thing but most of the things we do as hospital doctors make no difference to patient outcomes. For example, a patient with pneumonia needs 1. some kindness 2. maybe some oxygen 3. appropriate antibiotics. Blood tests won't help them, documenting the results of their neuro exam won't help them, collecting vast quantities of sputum/blood/urine/stool for cultures won't help them, etc.
I would be happy if an intern is kind and does the things that matter.
Also consider this:
Residents are human beings, the same class as patients. If you break your residents heart in the pursuit of perfect patient care then maybe you have forgotten this. I have never met a "useless" resident in 18 years in the public hospital system. Some were smarter than others, some were more organised and efficient than others, some were nicer than others, but all of them had their good points, and all did more good than harm.

Sheepish said...

Thanks for your comment, Anonymous. I think that basically we agree. My point was that often the "uselessness" of the intern originates not so much from the intern, but the supervisor's limited ability to adequately teach, train or discipline the intern.

You can't deny, however, that many interns need "the hard word" every now and again.

I would like to think that the ability to be kind to patients is a basic requirement of working as a health professional.

The other basic requirement is to be able to follow instructions. I don't expect my intern to decide which of my orders to follow or not follow - if I decide my patient needs a sputum sample for ZN stain, I expect my intern to organise it. An intern that chooses not to do the test because in their opinion TB is unlikely deserves a talking to. This should not break their heart - but they need to learn their lesson somehow.

My goal is not to train an "okay" intern. I want them to become as efficient and clinically acute as possible. Ultimately that means reaching a limit - either mine or theirs.

Carlos said...
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