A firm director writes about the growth of a resident

One of my greatest graduate medical education pleasures is watching new M.D.s evolve into physicians. Few faculty members enjoy the same broad vantage point that firm directors hold. The 3 year window during which we supervise, precept, and mentor residents with their continuity patients allows us to see them uniquely. We see them as they tentatively struggle to find the correct forms on the first day in ambulatory clinic, and later as they gain a confidence among their colleagues marking a successful transition to second year. We see them as they sort themselves into generalists and all variety of sub-specialists. We see them finally as they complete their residencies and commence the job of directing their own education. When I first set out to write about a success in graduate medical education, I was thinking of something I witnessed in a specific resident….. Retrospectively, witnessing her transition may be much more generalizable.

My resident arrived from a prestigious medical school full of optimism that science and study and diligence were master for any problem that an ambulatory clinic patient could present her. She dressed sharply, had a shiny stethoscope, and quick answers in her assessment and plan….. but was surprised by the subtleties as they unfolded in the first patient we shared. She clung to a naive optimism. A little more study and diligence would prevail. When a non-English speaking patient had difficulty in registration, she took him there herself and translated. When he had trouble getting a prescription, she picked it up at the pharmacy and shipped it to him.

Several months into internship she received a page from one of her newly assigned clinic patients. The woman was in pain. The pain was unbearable. She had no medication. No clinic appointments were available during the harried resident’s ICU rotation. Other doctors were not helping. The husband was outraged. The young resident prescribed medication over the phone in escalating doses while scrambling to find a way for the patient to be seen by anyone to initiate a comprehensive pain management strategy. With the patient’s calls spinning out of control, and frustrated by a system that seemed to make it impossible for her to meet the desperate patient’s needs, the resident paged me for help. I suggested that she gather a little background and, indeed, the patient was using multiple physicians and pharmacies. The betrayed resident lashed back at her manipulator. This was a bad patient. All symptoms were contrived. All problems were obstructionist. Any maneuvering by the patient was threatening. She lapsed into a self righteous and na

A pathology professor talks about the art of self evaluation

The story that I am recounting is actually when I was a medical student. I was in my surgery rotation and loving it, and I was paired up with a general surgeon who was notorious for being pretty rigorous and pretty crass. But for some reason the two of us got along extremely well, and so even on his private clinic days he allowed me to rotate with him.

It came to the end of the rotation, and I was pretty sure I was going to get a good evaluation from him. I went into his office, and he handed me a blank evaluation. He said, “You fill it out.” He said, “You have 15 minutes. Go into the other room while I am seeing this patient and fill out the evaluation.”

Of course, it was so hard for me. For somebody who tried to be humble, trying to rank yourself on a 5-point scale! I was looking at all the items on the form, and I thought, “You know, I really did do pretty well in this, but do I give myself a 5 for that?” So I tended to downgrade myself on some things. I turned it back to him after 15 minutes, and he looked at it, and he shook his head at me and handed me another blank one. He said, “Now fill it out honestly.” So I went back and again just couldn’t get myself to put 5’s down for anything. Again I turned it back to him, and he shook his head again, and he said, “I’m giving you one more chance.” He handed me another blank evaluation, and so I went back out – it was taking me much less time at this point – and I finally gave myself 5’s for a couple of things.

I went back into his office, and he took it from me and said, “Well, we’re getting there.” Then he pulled out an evaluation that he had already filled out, and he had pretty much given me outstanding evals all the way down the list.

It wasn’t the evaluation that sticks in my mind but our discussion afterwards. He said what he wanted to teach me more than anything else was to self-evaluate. He said that after medical school these evaluations would be far and few between, and it would be up to me to decide whether I was doing well or not, and I had to cultivate being honest with myself. He said that you can shape a dynamic career that way because if you are honest and know what you are good at, then you can capitalize on that. And if you know what you are not so good at, then you can either choose to avoid that or you can try to improve yourself so you are better in those particular areas.

I think the reason it stands out in my mind is that he was right on the money. Sometimes when I’m working with a resident or student, I can tell they just haven’t tapped into looking at themselves. They’re too worried about what everybody else thinks, and they’re not focusing on the joy of learning or the joy of capitalizing on the skills they do have. So I try to do that same thing – not assigning them a blank evaluation – but asking them to evaluate themselves and tell me what their strengths are. It’s hard for people to do that, and I think maybe that’s because we are so used to being graded and so used to always having something that needs improvement. Taking it from the other perspective is just as important, asking yourself, “What am I really good at?”

It’s very hard for them to do, and often I have to jumpstart the process by saying, “Okay, I am going to tell you something that you are really good at doing.” Then I ask, “Do you think that is a true evaluation?” They hear that it is okay to just put things out there on how they perceive themselves. What saddens me is that sometimes people really can’t see it. They don’t see that they are a good teacher or that they really do have a good eye or a sense of pathology or that they are efficient, or that they work well with the support staff. They haven’t realized that everybody is not that way.

I think we are all very good about saying what our shortcomings are. But being honest with what our strengths are can improve our whole lives – our work lives, even our personal lives – in knowing that we are smart, we are capable. We need to self reflect and realize our worth and that we are in this for a reason, and we are bringing things to the table that are unique.