To add to my worries, my PD sat in with two of my clinic based pt encounters last friday, i got feedback that my physical exams needed a lot of improvement, otherwise gave me feedback such as sit facing patient or use smaller words when talking to them.
However, when I went back and read my evaluation that was put in my file for those two encounters, my PD had written I behave like a medical student level M3 or 4 right now. They have pulled me from half a day's of rotation for tomorrow and are having me work with a third year resident 1:1.
After everything at this point, I really do not think I have a remote shot of continuing within the program.
1 I havent heard about residents recovering from such a nose dive.
2 my clinic attendings now come to see all of my patients 1:1 now.
I think the extent of trouble I am in is a lot and do not see a way out of this.
That sounds like a witch hunt, not an evaluation. I guarantee that you're not the only one who would get caught using big words or looking at the computer instead of the patient during an office visit. That is terribly unhelpful feedback unless there was more. There has to be a
reason the faculty have formed this impression of you and are now piling on and looking for reasons to support it. It's very likely at least one of these occurred.
A) There were series of incidences on the floor that someone may have reported. This triggered the Clinical Competency Committee to learn about you.
B) There was an attending (could have appeared nice - they usually do) who you really struggled to crack and they came out with a bad impression of you and hence effectively reported you.
C) Your demeanor relative to your residents comes off as clueless whether that is a product of experience, medical knowledge, anxiety, organization, etc. and that is caught by many of your attendings leading to consistently low evaluations.
Who are your fellow residents? If they're mostly IMGs, I could totally see this being the case of an AMG in a crowd of already experience IMG trainees where you stick out. I'm not trying to arm you with more excuses but trying to paint a picture for you to allow you to introspect and know what you need to try to improve.
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What you need to do:
1.) Thank your program director for his candor and for offering the PIP because you know this isn't an opportunity afforded to every resident.
Ask for specific things during the clinical encounter that you did wrong or suggested vs. what an R1 would suggest because R3s still use medical terminology and face the computer while typing. I suppose the physical exam is something, but no one's physical exam skills are amazing and some are stuck at the med student level. Figure out what it is in your clinical reasoning process/interview process that's awry because that's what you need to improve. Don't be too firm or else they'll think you're arguing, but genuinely ask them and say hey, I am really sad to hear I am at this level and was wondering (and please be honest/brutal with me) what exactly lead you to make these impressions of me. Don't ask it in a challenging way or argue.
2.) I unfortunately think your assessment as well as Hallowmann's is more or less accurate. They do not seem to have much confidence in you and are now basically going to start documenting/nitpicking to gather more data. My advice when in this situation is to not fundamentally change what you do. Now...if you're coming in late or arguing with colleagues/upper levels, stop that! When it comes to effort/work, I would not drive myself to the point of craziness. It will only make you look more flustered and attract more negative attention. Stay organized, stay focused,
and keep doing what you are already doing right. That's important. You may not be doing a good job but if there's just such a gross clinical deficit as they describe, it's going to take a lot more than 3 months and working with a PGY-3 for a day. Things will get worse acutely before they get better but I guarantee you people evaluating won't see it that way so at least maintain the facade that you know what you're doing or else you're literally asking people to criticize and evaluate you poorly.
3.) When working with the PGY-3, keep in mind you're still being assessed.
DO NOT tell this PGY-3 what your PD thought. If you do, you're basically poisoning the well for yourself and giving the PGY-3 resident ammunition to use against you and I guarantee they will unless they absolutely love you which is unlikely to happen over this short time course. This person isn't a safe space for you to air whatever you feel or to ask dumb questions to. Do not give him/her any information they do not already have about how you're currently doing. I guarantee you that even though this session's meant to be formative/help, the leadership will solicit an impression from the PGY-3. Act normally and then solicit their advice and have a good attitude about it. Afterwards, try to do everything you can to improve without going overboard. I guess if the PD makes it explicitly clear he will not ask the PGY-3 anything, then ask away but again I recommend you not advertise the fact that you're struggling. Word will spread the other residents and attendings.
4.) Your focus should be 100% on this, but you may want to start mentally preparing yourself for a probation come July and what your fallback will be if your contract is ultimately not renewed. This isn't so that you can make other plans but so you have some sense of what will happen next so you don't feel like the world is ending if you aren't successful in this endeavor of changing their minds.
5.) When you're making a plan with your attending run it through in your head like a dress rehearsal beforehand. Does it make sense? Say your patient has chest pain and your plan is do to a CXR, EKG, and Troponin in clinic (very basic, stupid example). Think about what you are looking for on the XR and will it change your management (
always ask yourself that). If it shows X, what will you next? Be prepared with those answers. Medical students (and even residents) order things reflexively and when asked why...they often give an incoherent jumbled answer. Don't do this or else you'll set youself up for trouble with attendings looking to prove a point. Even if they're happy to explain it to you, know that it will show up in the eval. If you can go through and give that sequence (if X-> Y), attendings may not just see you as completely clueless but instead say, "I understand you want to do a CXR to rule out an aortic dissection, do you really think it would be able to show an aortic dissection" to which you guys can have a discussion about and you two will be on the same wavelength as to where you went wrong instead of making people think you're all over the place...anyhow that's more for people who are chronically unorganized/scatterbrained and how to prevent them from being put under the radar, but it's probably still helpful for you.
It's very important to make your clinical plan obvious so people can follow it. Attendings get confused very easily and don't expect them to listen to or try to comprehend your thoughts. They want things in a straightforward, comprehendable manner. When it comes to a diagnosis, just put your money down on what you think it is and come up with your most likely diagnosis. Your differential should not miss anything you don't want to miss. Come up with a plan to rule out anything you don't want to miss and confirm anything that is the most likely.
Honestly, I'm 100% sure you've been given this lecture before, which is why I think you need to find someone safe (who's not judging you) to practice this with in real time. I can help you out if this is an area that you are struggling with. I have written a few cases this afternoon to go over with you if you're interested via PM.
6.) Keep me updated. I can help with some of the nitty gritty clinical reasoning stuff as I know IM fairly well.
