Teach me something!

21 09 2011

Halfway through my second week in family medicine, my 8th week of clerkships in general, and having been immersed in “real” medicine for just about 2 months has led to a number of realizations on my part.

The first of these epiphanies, which is the one that most affects my working hours, is that location isn’t as influential as one might think.  Sure, it’s great to do a rotation at certain  hospitals because you get perks, like free lunch (which is HUGE for us, mostly because it means we don’t have to spend time or money packing a lunch), but the real money is in the people that you work with.  Bottom line: if your residents suck, you won’t learn nearly as much.  Most people would think that the attendings make more of a difference, but let’s be honest, your contact time with them is minuscule in the grand scheme.

I think that’s part of the reason why I liked psych so much and still feel iffy about family.  My residents in psych were, in short, fantastic.  The majority of the time, they took an interest in both formal and informal teaching, and they always (well, within reason) took the time to answer every question that I had without making me feel totally stupid and useless, and those things made all the difference.  In family, though, it’s hit or miss.  Because I’m working with a different resident (and sometimes attending) every half-day, I’ve been able to interact with a number of different people.  A few have been awesome.  Some have made me think things like “Oh, God, WHY?” and “I wonder what my odds are of doing serious damage if I acted on that impulse to kick the wall in frustration.”

What makes the difference is really my level of involvement.  The residents that are a frustrating pain to work with are the ones who are so sure that I, the peon, will screw up royally with the patient that they let me observe, and that’s it.  Or, worse, won’t even let me into the room at all.  I understand that every single activity in which the resident includes me is going to take longer, and it’s going to to mess with the schedule and set them behind.  Tough cookies, it’s part of their job description to let me at least try to do something.  At the risk of sounding full of myself, I did not put myself through the grind of 4 years of premed in college and 2 grueling years of stress and isolation in medical school in order to shadow.  I had plenty of experience doing shadowing from the time I was in high school.  At this stage of the game, this clerkship needs to be about learning to do procedures, zeroing in on key symptoms, making a list of differential diagnoses, and coming up with treatment options.  In short, while I’m not a fan of pimping, it needs to happen.

I’m sure some of you are reading this, thinking “Ugh, what a passive-aggressive brat.”  To a degree, this is true.  Now I have never been passive about things that are irritating me, but there’s a line now, primarily because 1. patient care still trumps all and I do not want to put that in terrible jeopardy just because I want to learn to do things, and 2. I’m not sure how much weight my feedback has for those guys, and to be honest I’m not super keen on irritating the people who are evaluating me.  I’m also pretty blunt about asking questions and have not yet refined my ability to question their decisions without actually looking like I’m questioning their decisions.  So far I have been really proactive, too, about actually asking to do things, bt not all residents take the hint.

It is the combination of these reasons that found me last Thursday sitting in the precepting room of the office, looking up random things about patients that I wouldn’t get to see because my assigned resident for the afternoon had ditched me at around 2 PM after an hour of shadowing.  This particular resident speaks Russian, which apparently is in demand in the area, but while he knew I’d be with him that afternoon he chose to cancel the translator that had been scheduled for 2 of his patients.  Even though it was economical to do so, I still think it was kind of a douche move for him to do that and then, instead of telling me that I could work with a different person for a bit, told me to “go read something, I’ll come get you for the next one.”  Unfortunately, the next patient turned out to be a young woman who had a spontaneous abortion at 8 weeks and was in the office to receive that news.  Even though watching a real clinician break that news would have been beneficial, the resident decided not to allow me in the room.  Enter aforementioned conflicts.  At least he had the courtesy at 3 PM to come back to the room in which I was sitting and tell me this.

Unfortunately, he never came back after that, and somewhere around 3:30 one of the attendings noticed that I was still sitting in the same place, and she asked what was up.  When I told her (without adding my suspicion that I was being intentionally ditched) what had happened, she just gave me this sad look, said that “yeah, he needs to work on his teaching,” and spent a while answering some questions that I’d had about the nuances of cervical cancer screening before mercifully letting me go home (seriously, I have absolutely no problem staying late or coming early as long as I’m learning something, but I can sit and read at home).

Bottom line, the residents matter far more than the location of the clinical site.  And not all of the residents I’ve worked with have been crappy teachers.  A couple have been really awesome.  One talked me through my first speculum exam (in order to get STD cultures), and a couple of them have been great about always asking “So how would you treat this patient.”  The doc I worked with yesterday quizzed me a lot, and I had never been so thankful for pimping (I’ll probably regret this statement in a couple of months once I get into internal medicine). So there’s hope yet for family med, but at the moment I’m not loving it.

Note for those of you who are non-medical types:  When I talk about pimping, it’s a pretty simple process.  They ask you a clinical knowledge question (most of which are so vague that you don’t have a prayer unless you can read minds), and if by some minor miracle you happen to have just read about that condition and know the answer, they ask you subsequent, more difficult, questions until you get one wrong, at which point they give you the “Wow, you’re dumb, I can’t believe you made it to this point of medical school.  Clearly you aren’t studying enough, and I hope you suck less when you’re actually in charge of patient care.”  It’s a super morale-booster.

An example of pimping:

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