"Making too bold a statement" -- why is this a problem?

[WanderingDave]

For the second time during clinical rotations, I've just been faulted by an attending for "making too bold a statement".

It was an ER patient who'd been assaulted, but had a long history of trauma. Among other things, he complained of shoulder pain and decreased range of motion. He'd sustained a concussion and didn't remember the incident clearly, but basically told me he was sure he'd injured the shoulder in the fight. On physical exam, there was an abnormal bony prominence. When I presented the case to the attending, I stated with confidence that I thought the man's shoulder had dislocated, based on my H&P. I stated that I wanted to X-ray it. The attending agreed with me on the X-ray part, but gave me hell when he reexamined the patient and didn't see the types of posturing and resistance to movement that usually accompany shoulder separations.

So I wasn't experienced enough to diagnose a shoulder dislocation on physical exam, and didn't know the proper findings to look for. Now I know them. Great. I accepted these teaching points without complaint, and won't make the same mistake again when examining a shoulder. Lesson learned.

But what upsets me is how this attending (and one other on an earlier rotation) went out of his way to give me a hard time simply for taking a stab (no pun intended) at the case with aplomb. Yeah, I was wrong. But I didn't know that I didn't know, and had no intention to mislead or compromise patient care. When I politely but assertively told the attending this, he acted like I was giving him backtalk, and told me I needed more humility.

There's nothing I hate worse than hearing, "I think med students shouldn't open their mouths unless they know exactly what they're talking about." How am I to learn if I'm not allowed to make mistakes? I'll gladly correct my error if someone with more knowledge than me, and/or the objective evidence, contradicts me. But be a jerk to me for having the temerity to try, and that only encourages me not to even try.

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[McGillGrad]

You should always speak in differentials and order labs and tests to weed out other possible causes.

As a student, you will be chided for trying to diagnose without presenting and justifying a differential list.

Taking a jab is what non-physicians do. Any monkey can see a pattern and take a guess. Once you're a senior resident or attending your experience (or higher stature) allows you to forego the verbal differential ... but it is always churning in your mind because it is never about the diagnosis... it is about the 'process'

 

[WanderingDave]

You should always speak in differentials and order labs and tests to weed out other possible causes.

As a student, you will be chided for trying to diagnose without presenting and justifying a differential list.

Taking a jab is what non-physicians do. Any monkey can see a pattern and take a guess. Once you're a senior resident or attending your experience (or higher stature) allows you to forego the verbal differential ... but it is always churning in your mind because it is never about the diagnosis... it is about the 'process'

Thank you, McGillGrad. If this attending had taken the time to explain this to me calmly, respectfully, and simply, the way you just did, that's all it would've taken.

It strikes me that I was never formally taught how to present a patient, or given chances to practice it where it didn't count, and I could be critiqued. And truth be told, presenting patients is an activity I now kind of dislike, because it's been so 'school of hard knocks' learning it, and I've come to associate it with frustration and feeling humiliated. Has this been others' experience too? I really think 2nd year of med school should end with a short course on patient presentations, with an emphasis on the importance of wording things just so.

 

[turkeyjerky]

First, remember that you're never going to be able to anticipate the idiosyncratic preferences that different attendings and residents have regarding presentations. It's just not possible and you will never be able to make everyone happy. Second, yes as stated above it's important to have a differential in mind and understand that H&P is rarely going to give you the diagnosis, but I disagree with his overall tone and commend you for having the guts to state what you really think is going on.

The truth is that people spend a lot of time hemming and hawing about "inflammatory process" vs "neoplastic process" and it's all a bunch of gobbity-gook. Sure, don't close prematurely, but you gotta assess the patient and have a plan. You did that, and that puts you head and shoulders above most of your colleagues (even if you were wrong...)

 

[ScubaStarved]

I assume that you are a third year student on an ortho or ER rotation? If an ER rotation, it is unfortunate that you ended up there so early in the year, as it's one rotation that does require a great deal of general knowledge and many physical exams that you simply will not have learned yet. If an ortho rotation, I'd wonder why a resident was not available to help you with an unfamiliar exam and also to help you tighten your presentation.

That said, presenting cases/information only to the extent of your knowledge (while appearing confident and intelligent) is a critical skill that you will do well to practice early. As you note, they're not faulting you for boldness, they're faulting you for stabbing blindly and using a diagnosis name as a shortcut. If you have 10-15 minutes between interview and presentation, you'd do well to spend 5 of those minutes summarizing your findings and pertinent positives and negatives on a sheet of paper. Spend the last 10 minutes skimming the relevant uptodate or emedicine article on the patient's chief problem.

If your attending waits for you outside the ER curtain, the above advice is obviously useless. If that's the case and it's an exam you're unfamiliar with, I'd advise you to present to the best of ability while acknowledging your unfamiliarity with shoulder exams:

This is an intoxicated 32yo male with history of multiple traumas who presents with shoulder weakness and pain and hand numbness s/p physical altercation complicated by concussion. He has poor recollection of the event but does remember blah blah blah..
...
His L shoulder exam is notable for an abnormal bony prominence as well as weakness of abduction and internal/external rotation. His shoulder is extremely tender to light touch and he complains of increased pain with any activity. His left hand has markedly reduced grip strength and obvious proprioceptive defect to the mid-forearm.
...
#1. LOC s/p head trauma with neuro exam significant for multiple LUE deficits -- This patient's LUE are more likely due to a shoulder injury, but the history of head trauma with LOC is concerning. Per our institution's head trauma protocol, a non-con CT was obtained which showed no evidence of acute intracranial bleed or fracture. We'll keep him on QXH neuro checks and blah blah blah...
#2. Shoulder injury -- We first need an X-ray of his left shoulder to further evaluate his injury. From my brief reading on the subject, I believe the bony prominence, the extreme pain with activity, the weakness with rotation, and hand numbness are most concerning for shoulder dislocation with neurovascular compromise. Less likely alternatives include fracture, tendon injury, or a spinal/intracranial cause of his deficit. To be honest, I have not yet had instruction in a systematic shoulder exam and will appreciate any tips when we examine him together.
#3. If this is an ortho or ER attending, they probably won't let you get much past 1 or 2 points.

 

[McGillGrad]

Thank you, McGillGrad. If this attending had taken the time to explain this to me calmly, respectfully, and simply, the way you just did, that's all it would've taken.

It strikes me that I was never formally taught how to present a patient, or given chances to practice it where it didn't count, and I could be critiqued. And truth be told, presenting patients is an activity I now kind of dislike, because it's been so 'school of hard knocks' learning it, and I've come to associate it with frustration and feeling humiliated. Has this been others' experience too? I really think 2nd year of med school should end with a short course on patient presentations, with an emphasis on the importance of wording things just so.

I have never understood why they don't teach us simple things like that right before we go off to clinicals. It would go a long way to help us be more useful and efficient.

Looking at it from the other side, I now tell my students what's expected and how to do it properly. It helps with their education and with flow on the floor.

 

[ScubaStarved]

And truth be told, presenting patients is an activity I now kind of dislike, because it's been so 'school of hard knocks' learning it, and I've come to associate it with frustration and feeling humiliated. Has this been others' experience too? I really think 2nd year of med school should end with a short course on patient presentations, with an emphasis on the importance of wording things just so.

Communicating about patients concisely and accurately is one of the hardest things to learn, in my opinion. You should not feel behind or inadequate because you haven't mastered it after three months and with no formal training. It's something you'll become better at with time and with increased understanding of your patients' pathologies. It really, really does get easier as the year goes progresses. If you've residents available, let them know that you'd appreciate help with your A/Ps and then verbally present your plan just as if doing so for the attending. They will correct your language and sharpen your plan, resulting in much tighter presentations and ultimately better grades. Rather than find you slow or incompetent, I've found that most (decent human being) residents respond quite positively to these requests and are happy to help. It further reminds them of your level of training (which is early), and they can better anticipate what you'll need guidance with in the future.

 

[2012mdc]

Thank you, McGillGrad. If this attending had taken the time to explain this to me calmly, respectfully, and simply, the way you just did, that's all it would've taken.

It strikes me that I was never formally taught how to present a patient, or given chances to practice it where it didn't count, and I could be critiqued. And truth be told, presenting patients is an activity I now kind of dislike, because it's been so 'school of hard knocks' learning it, and I've come to associate it with frustration and feeling humiliated. Has this been others' experience too? I really think 2nd year of med school should end with a short course on patient presentations, with an emphasis on the importance of wording things just so.

At my school we do get some limited experience with doing H&P's and presenting them during 2nd year. We still suck at the beginning of the 3rd year but we are familiar with the format.

 

[meowdoc]

med school sucks

suck it up and move on

 

[WanderingDave]

ScubaStarved, that was a very helpful post. I'm definitely going to be using a lot of "concerning for [diagnosis]" and "I'm concerned about [diagnosis]", in the context of my H&P findings and the tests I want to order, when I present from now on.

Because believe it or not, I'm already used to thinking in a differential diagnosis (and workup) sort of way about the cases I see, but am not well trained at verbalizing it in such a way that my superiors know that that's how I'm thinking. This is unbelievably frustrating, especially since I'm a highly verbal person and usually good at phrasing things in ways so that my intentions and thought processes are clear. The bright side to this is that I can easily master the requisite verbiage for this situation if someone just walks me through it a few times patiently. I think when they and I have some free time next shift, I'm going to ask some residents whom I get along with to critique my phrasing of patient presentations.

The other problem is the double standard that McGillGrad referred to, whereby it's acceptable for attendings and senior residents to speak a certain way about pts they just saw, but I get beaten over the head for being hasty if I ape their style. I couldn't understand, for the longest time, why I was doing the same thing but being treated differently. I see now that this is a matter of "learn the right way before you take shortcuts". I wish this were better taught.

A lot of you assume I'm a 3rd year student. I'm ashamed to say I'm actually a 4th year student. I only did two 3rd year rotations which necessitated presenting patients to higher-ups, and both of these rotations taught it rather poorly and sporadically.

I am indeed on EM now.

 

[officedepot]

I see now that this is a matter of "learn the right way before you take shortcuts". I wish this were better taught.

A lot of you assume I'm a 3rd year student. I'm ashamed to say I'm actually a 4th year student. I only did two 3rd year rotations which necessitated presenting patients to higher-ups, and both of these rotations taught it rather poorly and sporadically.

I am indeed on EM now.

They really aren't taking shortcuts (hopefully) if they are good. They should be think of the most likely causes of any chief complaint and history and a work-up. In your case for example, I am no expert on shoulder exams but perhaps doing a physical is essentially diagnostic of one. Thus doing the correct exam will pretty much give you a diagnosis. Residents probably know how to do this.

Don't think just because you took a stab you can't present. Just give your entire differential and work-up. You can say what you think is most likely but don't neglect the others such as fracture and what not.

I agree presenting is kind of annoying mostly because residents and attendings want us to do it a certain way. Residents can pretty much present to the attending however they want. But students have to say everything in a certain order.

 

[WanderingDave]

Residents can pretty much present to the attending however they want. But students have to say everything in a certain order.

Not only that, but many will want a certain script used, with really no deviations or rephrasings whatsoever. Scientists are incredibly stingy and exacting with words -- there is generally only one best correct way to phrase anything formally, and to not remember it and say it verbatim irks the highly scientific mind greatly. (The stereotypical science geek's propensity to remember and recite Monty Python sketches absolutely verbatim says a lot about how their minds process verbiage.) This definitely feels like dancing in fetters to someone with a stronger background in the humanities and language arts than the sciences. But since the goal is flawless communication and prompt, correct patient care, I choose to take this as a challenge rather than try and rebel. Especially since, as I can see, things will get a little looser as I move up the food chain.

I think this is a matter of workplace rapport and professional trust. Attendings and residents have selected each other through the match process, and once the attending has enough faith that the resident is going through the correct mental machinations to approach a case, he'll accept liberties taken in the verbal presentation. Whereas, no such trust exists toward students, and as my example shows, such a level of trust isn't yet warranted.

 

[Brewmeister]

I've found that no matter what you do, the resident/attending will find some fault. Odds are they won't tell you about this until your final evaluation and odds are they the "faults" are things that you have been doing correctly but the resident/attending assumes you suck at because you are early in your 3rd year. Also, they never have any advice on how to improve on said faults.

 

[J-Rad]

For the second time during clinical rotations, I've just been faulted by an attending for "making too bold a statement".

It was an ER patient who'd been assaulted, but had a long history of trauma. Among other things, he complained of shoulder pain and decreased range of motion. He'd sustained a concussion and didn't remember the incident clearly, but basically told me he was sure he'd injured the shoulder in the fight. On physical exam, there was an abnormal bony prominence. When I presented the case to the attending, I stated with confidence that I thought the man's shoulder had dislocated, based on my H&P. I stated that I wanted to X-ray it. The attending agreed with me on the X-ray part, but gave me hell when he reexamined the patient and didn't see the types of posturing and resistance to movement that usually accompany shoulder separations.

So I wasn't experienced enough to diagnose a shoulder dislocation on physical exam, and didn't know the proper findings to look for. Now I know them. Great. I accepted these teaching points without complaint, and won't make the same mistake again when examining a shoulder. Lesson learned.

But what upsets me is how this attending (and one other on an earlier rotation) went out of his way to give me a hard time simply for taking a stab (no pun intended) at the case with aplomb. Yeah, I was wrong. But I didn't know that I didn't know, and had no intention to mislead or compromise patient care. When I politely but assertively told the attending this, he acted like I was giving him backtalk, and told me I needed more humility.

There's nothing I hate worse than hearing, "I think med students shouldn't open their mouths unless they know exactly what they're talking about." How am I to learn if I'm not allowed to make mistakes? I'll gladly correct my error if someone with more knowledge than me, and/or the objective evidence, contradicts me. But be a jerk to me for having the temerity to try, and that only encourages me not to even try.

Barring something dramatic missing from the first part of the story, has it occurred to you that it may have been this that earned you the consternation of the attending. Was there any particular reason to say anything other than: "Thanks, I'll apply that next time...I appreciate the teaching"? At a minimum you probably came off as defensive and possibly juvenile. It would be a short step over to disrespectful depending on your particular words and tone. It is true that many, many physicians lack proper skills in giving feedback and evaluation (and these are two separate and distinct things), and this doc may be one of the many; however it behooves you to learn the value of responding to criticism in such a way that demonstrates humility and a willingness to learn. This sometimes includes swallowing your pride and saying as little as is reasonably possible while you listen maximally. Fortunately not every doc will be as brusque as this one and this is a good lesson in picking yourself up and moving on. There should be no PTSD here, just follow the good advice given later in this thread. I would add that if there is something that you are not confident in, then it is OK to say that you might not be completely confident in your findings (maybe asking for the doc to help you get a better exam?). I do think this doc failed in taking a teaching moment if he didn't ask about the pertinent +/- associated with your proposes diagnosis and making you expand into a differential, but I still think your response was sub-optimal.

You should always speak in differentials and order labs and tests to weed out other possible causes.

As a student, you will be chided for trying to diagnose without presenting and justifying a differential list.

Taking a jab is what non-physicians do. Any monkey can see a pattern and take a guess. Once you're a senior resident or attending your experience (or higher stature) allows you to forego the verbal differential ... but it is always churning in your mind because it is never about the diagnosis... it is about the 'process'

Thank you, McGillGrad. If this attending had taken the time to explain this to me calmly, respectfully, and simply, the way you just did, that's all it would've taken.

It strikes me that I was never formally taught how to present a patient, or given chances to practice it where it didn't count, and I could be critiqued. And truth be told, presenting patients is an activity I now kind of dislike, because it's been so 'school of hard knocks' learning it, and I've come to associate it with frustration and feeling humiliated. Has this been others' experience too? I really think 2nd year of med school should end with a short course on patient presentations, with an emphasis on the importance of wording things just so.

Yes, it should. Mine did exactly that. It was built into the whole year, but in the second half of the second year we had three person teams that were given a case. On the scheduled evening when they were expected to present the team was grilled on the case by a panel of docs. Each member had a particular role in the case (though all had to know each role). The first was the "This is a Y year old gender patient with a PMH of Z who presents with a complaint of" The clinicotemporal profile of the complaint was discussed as well as findings. Last person up had the "The DDx of X symptom in Y year old gender patient with a PMH of Z is A, B, C..." and the discussion of pertinent +/- and what we thought the most likely things were on the DDx list (we learned the VINDICATE mnemonic). It was a nerve wracking but very useful exercise.

I assume that you are a third year student on an ortho or ER rotation? If an ER rotation, it is unfortunate that you ended up there so early in the year, as it's one rotation that does require a great deal of general knowledge and many physical exams that you simply will not have learned yet. If an ortho rotation, I'd wonder why a resident was not available to help you with an unfamiliar exam and also to help you tighten your presentation.

That said, presenting cases/information only to the extent of your knowledge (while appearing confident and intelligent) is a critical skill that you will do well to practice early. As you note, they're not faulting you for boldness, they're faulting you for stabbing blindly and using a diagnosis name as a shortcut. If you have 10-15 minutes between interview and presentation, you'd do well to spend 5 of those minutes summarizing your findings and pertinent positives and negatives on a sheet of paper. Spend the last 10 minutes skimming the relevant uptodate or emedicine article on the patient's chief problem.

If your attending waits for you outside the ER curtain, the above advice is obviously useless. If that's the case and it's an exam you're unfamiliar with, I'd advise you to present to the best of ability while acknowledging your unfamiliarity with shoulder exams:

I have never understood why they don't teach us simple things like that right before we go off to clinicals. It would go a long way to help us be more useful and efficient.

Looking at it from the other side, I now tell my students what's expected and how to do it properly. It helps with their education and with flow on the floor.

I agree that it's unfortunatle that this isn't universally done. I commend you for taking the initiative to help overcome that. Too many residents are too content to do the minimum when it comes to teaching but are willing to criticize maximally.

Communicating about patients concisely and accurately is one of the hardest things to learn, in my opinion. You should not feel behind or inadequate because you haven't mastered it after three months and with no formal training. It's something you'll become better at with time and with increased understanding of your patients' pathologies. It really, really does get easier as the year goes progresses. If you've residents available, let them know that you'd appreciate help with your A/Ps and then verbally present your plan just as if doing so for the attending. They will correct your language and sharpen your plan, resulting in much tighter presentations and ultimately better grades. Rather than find you slow or incompetent, I've found that most (decent human being) residents respond quite positively to these requests and are happy to help. It further reminds them of your level of training (which is early), and they can better anticipate what you'll need guidance with in the future.

Again,

Not only that, but many will want a certain script used, with really no deviations or rephrasings whatsoever. Scientists are incredibly stingy and exacting with words -- there is generally only one best correct way to phrase anything formally, and to not remember it and say it verbatim irks the highly scientific mind greatly. (The stereotypical science geek's propensity to remember and recite Monty Python sketches absolutely verbatim says a lot about how their minds process verbiage.) This definitely feels like dancing in fetters to someone with a stronger background in the humanities and language arts than the sciences. But since the goal is flawless communication and prompt, correct patient care, I choose to take this as a challenge rather than try and rebel. Especially since, as I can see, things will get a little looser as I move up the food chain.

I think this is a matter of workplace rapport and professional trust. Attendings and residents have selected each other through the match process, and once the attending has enough faith that the resident is going through the correct mental machinations to approach a case, he'll accept liberties taken in the verbal presentation. Whereas, no such trust exists toward students, and as my example shows, such a level of trust isn't yet warranted.

Yes. Think of it as like learning an instrument via formal lessons. In the beginning, it is formal and regimented. It is much later, after you have mastered the basics that you will have the freedom to improvised. And it takes a lot of pride swallowed to understand the bolded, but if you do, then you should be able to move on well.

 

[J-Rad]

A lot of you assume I'm a 3rd year student. I'm ashamed to say I'm actually a 4th year student. I only did two 3rd year rotations which necessitated presenting patients to higher-ups, and both of these rotations taught it rather poorly and sporadically.

This is one of the unfortunate side effects of the double edged sword that is the clinical education of DO medical students. Let me guess: almost all community based preceptors for your core rotations?

 

[WanderingDave]

Barring something dramatic missing from the first part of the story, has it occurred to you that it may have been this that earned you the consternation of the attending. Was there any particular reason to say anything other than: "Thanks, I'll apply that next time...I appreciate the teaching"?

That is how I reacted to his berating, pretty much the entire 12h shift. I just said "OK", in a neutral tone of voice. If it was him correcting my choice of words, I'd just say "OK", and then go back and say it his way, without missing a beat. I never let my enthusiasm drop or copped a defensive tone, even after being corrected or criticized.

Trust me, I'm mature enough to know that if someone my senior has valuable knowledge to impart to me that I don't yet have (and need), then clearly it behooves me to listen and heed their advice, which I did. But unless I've done someone wrong, shirked a responsibility, or done something morally reprehensible, I owe no one any kind of submissive posturing.

At a minimum you probably came off as defensive and possibly juvenile. It would be a short step over to disrespectful depending on your particular words and tone.

It went approximately like this:
Attending: "You said he had a shoulder separation as though you knew, but you didn't know."
Me: "I understand, doctor. However, I didn't know that I didn't know. I was certain because I mistakenly thought I had enough evidence from the physical exam. Now I know better."
Attending: "No, you were not certain! You need to be more humble about your level of knowledge given the stage of your training."
Me: OK.

Essentially, I took umbrage to the implied assertion that I was being deliberately careless, when in fact I actually had given due thought to the case, just not the right kind of thought. After 12h of yessing this dude to death and doing exactly as he said, that was really the last straw. I don't think you could really call my response immature, disrespectful, or unprofessional.

Yes, it should. Mine did exactly that.

I agree that it's unfortunatle that this isn't universally done. I commend you for taking the initiative to help overcome that. Too many residents are too content to do the minimum when it comes to teaching but are willing to criticize maximally

I'm glad some schools, like your alma mater, are on the right track!

What kills me is when some higher-up in my clinical training preemptively scorns or shames me for not knowing some skill that in his mind I "should know by now", when no one has taught it to me, no one has given me the chance to practice it in a no-stakes setting, and no one has even warned me it's a skill people will expect me to bring with me.

It was made amply clear in 1st and 2nd year that my clinical trainers would expect me to already know how to write a SOAP note and take a H&P. I took these lessons seriously, and made sure my notes and H&Ps were polished before I began rotations. But I was taught very little on how to present a patient, how to formulate a differential diagnosis, how to write orders, how to do a consult, who and how to ask for help with a tricky case, and when I ought to be taking the initiative to round on my patients. These are all things that have gotten me yelled at and treated like an idiot when I failed at them without trying to. When I learn anything, all I ask is to be shown the right way once, and then be given one chance to try it without penalty. If after being taught and corrected I still get it wrong, then sure, feel free to hold it against me. Otherwise that's just subpar education.

Yes. Think of it as like learning an instrument via formal lessons. In the beginning, it is formal and regimented. It is much later, after you have mastered the basics that you will have the freedom to improvised. And it takes a lot of pride swallowed to understand the bolded, but if you do, then you should be able to move on well.

Thanks for taking the time to give me so much solid advice, J-Rad. I hope you don't get the impression I'm a man who cuts off his nose to spite his face. Make it clear that something is expected of me, and then fault me for not delivering, and you'll find me apologetic and humble as pie. Faulting me for not delivering on something I never realized was my duty is a whole other kettle of fish. If medical school has taught me anything general about life, it's the difference between a good teacher and a bad one.

This is one of the unfortunate side effects of the double edged sword that is the clinical education of DO medical students. Let me guess: almost all community based preceptors for your core rotations?

Heh, yep.

 

[Rendar5]

It went approximately like this:
Attending: "You said he had a shoulder separation as though you knew, but you didn't know."
Me: "I understand, doctor. However, I didn't know that I didn't know. I was certain because I mistakenly thought I had enough evidence from the physical exam. Now I know better."
Attending: "No, you were not certain! You need to be more humble about your level of knowledge given the stage of your training."
Me: OK.

Essentially, I took umbrage to the implied assertion that I was being deliberately careless, when in fact I actually had given due thought to the case, just not the right kind of thought. After 12h of yessing this dude to death and doing exactly as he said, that was really the last straw. I don't think you could really call my response immature, disrespectful, or unprofessional.

The reason you got the response from the attending is that you were providing an excuse/explanation for your mistake when none was sought. I have the same bad habit myself, even as a senior resident.

 

[2012mdc]

The reason you got the response from the attending is that you were providing an excuse/explanation for your mistake when none was sought. I have the same bad habit myself, even as a senior resident.

It's a very hard habit to break. In medicine sometimes it's better to resist the urge to explain yourself especially when it won't change anything. You will be wrong a lot and you don't have to explain it unless asked

The best response would have been "Ok. Thank you sir. I will review shoulder injuries." Not only are you not being defensive but you are being proactive in correcting your mistakes.

I'm not accusing you of being like this but many med students think they know more than they do and attendings/residents love to jump on that.

 

[WanderingDave]

It's a very hard habit to break. In medicine sometimes it's better to resist the urge to explain yourself especially when it won't change anything. You will be wrong a lot and you don't have to explain it unless asked

Fair enough. I guess there's no point wasting time and energy in arguing about things that don't affect patient care one way or the other.

As an aside, I can see clearly now why people socialized into team sports their whole childhoods (and/or possibly business or military culture as young adults) are better prepared for many medical learning environments than people (like myself) who were never socialized that way. I think this is especially true for EM and IM, where working relationships with other doctors are more salient and professionally important than those with patients.

 

[J-Rad]

Fair enough. I guess there's no point wasting time and energy in arguing about things that don't affect patient care one way or the other.

As an aside, I can see clearly now why people socialized into team sports their whole childhoods (and/or possibly business or military culture as young adults) are better prepared for many medical learning environments than people (like myself) who were never socialized that way. I think this is especially true for EM and IM, where working relationships with other doctors are more salient and professionally important than those with patients.

Rendar is absolutely correct. I also think your observation is correct if I interpret it correctly. I was never much of a sports guy, but had some experience in the military which was helpful. One of the things it taught me was the "thousand-yard-stare" state of mind. This is the one in which you tolerate someone berating you by staring through them (it still looks as though you are paying attention since you are looking straight at them). It's not so much about the physical act of staring, rather the mental state you must be in to let these types of situations roll off your back and to accept that it is part of "the game". The truth is that I despise this type of "teaching" and think little of those who employ it, however, I understand that there are many out there who mistakenly believe in its value, mostly out of intellectual laziness and the inability to form more effective teaching modalities. I think there can be a value in the "socratic method", but medicine is not basic training and teaching physicians are not TI/DI/DSs. Accept the game and move on. This guy is a prick...give nothing to these type of people other than your attention and your "yes sirs", "no sirs", and "thank you sirs". The most malignant of these vultures are like Cartman waiting to lick your tears. Offering even the tiniest of an excuse is an opportunity for exploitation; do not give it.

Beside this lesson, take whatever knowledge he can impart because even the malignant douches can have something to teach. And for you in particular, realize that you need to be better. When you get to residency you aren't going to be able to say "don't fail me, please; all my third year was at community hospitals and I didn't learn how to navigate the academic medicine waters". If you don't believe that this is something that can happen, go read this thread from post #484 through the conversation it generated and realize that this was a comment from someone active in GME in an institution with the greatest percentage of DOs in the country aside from the few osteopathic hospitals left: http://forums.studentdoctor.net/showthread.php?t=118576&page=10. I know you didn't ask for this comment and it may come off as unkind, but I offer the advice out of kindness and true well wishes. I would advise scheduling some academically rigorous rotations for the rest of your fourth year-especially in fields related to your residency and career aspirations. It will make your transition to residency easier.

 

[45408]

Second, yes as stated above it's important to have a differential in mind and understand that H&P is rarely going to give you the diagnosis

Uh, what? It most certainly will give you many diagnoses, and in some specialties, virtually all of them. Your H&P gives you most of your diagnoses in a specialty like derm, and it gives us quite a few of our diagnoses in surgery. Appendicitis, inguinal hernias, most anorectal problems, numerous vascular disorders, etc. can all be diagnosed with an H&P.

 

[45408]

The other problem is the double standard that McGillGrad referred to, whereby it's acceptable for attendings and senior residents to speak a certain way about pts they just saw, but I get beaten over the head for being hasty if I ape their style. I couldn't understand, for the longest time, why I was doing the same thing but being treated differently. I see now that this is a matter of "learn the right way before you take shortcuts".

They also don't trust you. It's not personal, but they don't know what you can/can't do with any sense of reliability. Can you diagnose peritonitis or an S3? They don't know.

Also, it's about learning the right way before you cut to the chase. Even residents still have to give the long presentation at times (such as at morning/noon conferences when you're presenting a case, or at M&M), so you learn it early. Plus, when I'm dictating an H&P, it's like giving an ultra-long patient presentation. Besides, some staff will still want the the long presentation if they're the detail-oriented type.

It's a very hard habit to break. In medicine sometimes it's better to resist the urge to explain yourself especially when it won't change anything. You will be wrong a lot and you don't have to explain it unless asked

Even then, sometimes you should suppress an answer! The question "What were you thinking??" may be best met with a thoughtful nod.

 

[McGillGrad]

Uh, what? It most certainly will give you many diagnoses, and in some specialties, virtually all of them. Your H&P gives you most of your diagnoses in a specialty like derm, and it gives us quite a few of our diagnoses in surgery. Appendicitis, inguinal hernias, most anorectal problems, numerous vascular disorders, etc. can all be...

I couldn't agree more.

 

[Rendar5]

Second, yes as stated above it's important to have a differential in mind and understand that H&P is rarely going to give you the diagnosis, but I disagree with his overall tone and commend you for having the guts to state what you really think is going on.

Now that's too bold of a statement as prowler pointed out.

lol sorry i couldn't resist.

 

[todo]

i'm trying to sympathize w. you, and although I agree that the doc was probably out of line I also think your first mistake was talking back, and your second one was doing it "assertively"

Do you actually think you're teaching someone a lesson, that he'll change his ways? Or did you do it to make yourself feel better? You basically just punched yourself in the junk.

I think part of the job is learning how to deal with these things (and worse) without having to talk back.

There was a thread out there called "I'm highly sensitive and take humiliation very poorly" that deals with similar subject matter.

It's an interesting area. Being disrespected and humiliated make some people lose control - can you operate when your mind is being hit by all these other stressors?

 

[turkeyjerky]

Uh, what? It most certainly will give you many diagnoses, and in some specialties, virtually all of them. Your H&P gives you most of your diagnoses in a specialty like derm, and it gives us quite a few of our diagnoses in surgery. Appendicitis, inguinal hernias, most anorectal problems, numerous vascular disorders, etc. can all be diagnosed with an H&P.

I think you misunderstood the flavor of my post. I was responding to a guy who said to never give an opinion at all, just a list of possibilities. But, yeah, most things require a confirmatory test. Maybe I'm wrong though, are you guys revascularizing w/o getting an arteriogram? Routine appendectomies w/o imaging? Pushing lytics w/o a Head CT?

 

[45408]

I think you misunderstood the flavor of my post. I was responding to a guy who said to never give an opinion at all, just a list of possibilities. But, yeah, most things require a confirmatory test. Maybe I'm wrong though, are you guys revascularizing w/o getting an arteriogram? Routine appendectomies w/o imaging? Pushing lytics w/o a Head CT?

1. Revascularize without an a-gram? No, but we would take someone to the OR for a thrombectomy without any confirmatory studies if they've got a-fib, subtherapeutic INR, a strong femoral pulse, a cold leg and good pedal pulses on the contralateral leg.

2. Appy without imaging? Sure, in a young patient with a reasonable story. An obese 70-year old woman? No, because it could be her cancer eroding through her colon, and I don't want to do a right hemi through a Rocky-Davis incision.

3. You would never do that, because it's contraindicated.

Think of all the diagnoses that an internist or pediatrician makes in a day, without ever sending a patient for further studies - musculoskeletal issues, ear infections, rashes, etc.

 

[SouthernSurgeon]

1. Revascularize without an a-gram? No, but we would take someone to the OR for a thrombectomy without any confirmatory studies if they've got a-fib, subtherapeutic INR, a strong femoral pulse, a cold leg and good pedal pulses on the contralateral leg.

2. Appy without imaging? Sure, in a young patient with a reasonable story. An obese 70-year old woman? No, because it could be her cancer eroding through her colon, and I don't want to do a right hemi through a Rocky-Davis incision.

3. You would never do that, because it's contraindicated.

Think of all the diagnoses that an internist or pediatrician makes in a day, without ever sending a patient for further studies - musculoskeletal issues, ear infections, rashes, etc.

Exactly...I've definitely done #1 and #2.

 

[Rendar5]

I think you misunderstood the flavor of my post. I was responding to a guy who said to never give an opinion at all, just a list of possibilities. But, yeah, most things require a confirmatory test. Maybe I'm wrong though, are you guys revascularizing w/o getting an arteriogram? Routine appendectomies w/o imaging? Pushing lytics w/o a Head CT?

just to be a stickler, CVA is a purely clinical diagnosis when it comes to lytics. head CT rules out other diagnoses, it is never used to make the diagnosis.

 

[turkeyjerky]

1. Revascularize without an a-gram? No, but we would take someone to the OR for a thrombectomy without any confirmatory studies if they've got a-fib, subtherapeutic INR, a strong femoral pulse, a cold leg and good pedal pulses on the contralateral leg.

2. Appy without imaging? Sure, in a young patient with a reasonable story. An obese 70-year old woman? No, because it could be her cancer eroding through her colon, and I don't want to do a right hemi through a Rocky-Davis incision.

3. You would never do that, because it's contraindicated.

Think of all the diagnoses that an internist or pediatrician makes in a day, without ever sending a patient for further studies - musculoskeletal issues, ear infections, rashes, etc.

First, that wasn't the patient I was referring to, critical presentations are a different situation with different a different decision tree. Second, I don't think its very common to take appys to the OR w/o imaging confirmation. Maybe it should be, maybe it shouldn't, but I don't think it's very common, even with classic stories. I'll leave it at that.

I'm not sure if you're feeling the need to 'put me in my place' or if you're just on an Osler and Cope binge, but to argue that you can just lay hands on a patient and make the clinical diagnosis w/o confirmatory labs or imaging is simply not true in most circumstances. Think about MI, pneumonia, pancreatitis, pericarditis, cardiac tamponade, stroke, myopathies, zenker's diverticulum, achalesia, hepatitis, stroke. All have classic history and physical exam findings, so are you really gonna omit the ekg, troponins, cxr, upper GI's, EMGs, MRIs, liver panels, lipases, etc.

just to be a stickler, CVA is a purely clinical diagnosis when it comes to lytics. head CT rules out other diagnoses, it is never used to make the diagnosis

Yeah I know that

 

[Rendar5]

I think it's more that you seemed to be discounting the import of the H&P in your initial post, and seemed to suggest that it doesn't often lead you to the correct answer without further testing. Both of which are false as the diagnosis more often than not is within your top 2-3 differential.

On your further explanation, this does not appear to be what you meant with your original statements.

 

[45408]

First, that wasn't the patient I was referring to, critical presentations are a different situation with different a different decision tree. Second, I don't think its very common to take appys to the OR w/o imaging confirmation. Maybe it should be, maybe it shouldn't, but I don't think it's very common, even with classic stories. I'll leave it at that.

I'm not sure if you're feeling the need to 'put me in my place' or if you're just on an Osler and Cope binge, but to argue that you can just lay hands on a patient and make the clinical diagnosis w/o confirmatory labs or imaging is simply not true in most circumstances. Think about MI, pneumonia, pancreatitis, pericarditis, cardiac tamponade, stroke, myopathies, zenker's diverticulum, achalesia, hepatitis, stroke. All have classic history and physical exam findings, so are you really gonna omit the ekg, troponins, cxr, upper GI's, EMGs, MRIs, liver panels, lipases, etc.

Neither. By the time someone has a problem severe enough to come to the ED, yes, I would agree that they frequently need some confirmatory testing. Plus, these days, patients present much earlier in their course and have more diagnostic insecurity with regard to their disease process. My point is the statement that the "H&P is rarely going to give you the diagnosis" is simply wrong.

In a hospital setting, your H&P may be inadequate to confirm your diagnosis before you commit someone to a major operation/procedure (or keep them from having one), but that's just one portion of health care today. You skipped right over the part where I mentioned that most internists, pediatricians, psychiatrists, dermatologists, etc. make most of their diagnoses based on an H&P, in their offices, every single day.

Furthermore, I added on some very common examples of major operations that I've committed people to just based on an H&P. The three reasons that people get imaging for most/all cases of appendicitis are the medicolegal climate in the US, diagnostic insecurity in your physical exam, and the desire to really "sell" your patient to the surgical consultant ("Hi, I've got CT-confirmed appendicitis, come take the pt out of my ER/clinic").

 

[group_theory]

If you don't have a good differential diagnosis (from the H&P), then how will you know what tests or studies to order (and more importantly, how to interpret the results of those tests/studies when they come back)