Passive Aggressive

[FutureDoc86]

I am going into Pediatrics but I've noticed this issue for the longest time at least at this program I am at (at a huge children's hospital)
Why are some Pediatricians soo Passive Aggressive? They nit pick at the smallest things on Presentations. What are your thoughts?

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[J-Rad]

That physicians, as a breed, are a passive aggressive bunch. I always found the internists to be the biggest nitpickers, but I've worked with a few pediatricians who were the same way (once worked with a cardiologist who, while doing gen peds floor attending on the weekend, made rounds last four hours for five patients. One of our pulmonologists was equally as talented at wasting time as gen peds attending). Can be very program dependent, and obviously very individual dependent. I think the tighter grip some pediatricians seem to hold on their patients may magnify the appearance you percieve, but I don't think they're much worse than a lot of others.

 

[Bernardo_11]

I always thought Passive Aggressive to mean a behavior where, as an act of rebellion/oppositional thinking, the person seems lazy and does not follow through with assigned jobs/duties. It's like asking someone who works for you to file some charts, he/she agrees to do it later, but in reality he/she is thinking, "If that jerk of a boss thinks I'm going to do that task with what he's paying me, he's got another thing coming."

What you seem to describe is more anal retentive behavior, being so particular about details that it is obstructive to the flow of work. Sometimes I agree it can go overboard, but when you are taking care of really sick kids, you want to make sure all those nitty gritty details are covered. You want to be a little anal retentive when it comes to working in the PICU, NICU, and heme-onc floors where most of the kids have multiple problems involving multiple body systems.

Now if it is more like someone spending 5 hours to round on 5 patients being admitted for bronchiolitis, reactive airways disease exacerbations, AGE/dehydration, fever rule out sepsis, and other "bread and butter" cases, I can see how that can be irritating..... especially if there is no real teaching involved.

Nardo

 

[FutureDoc86]

Yea I meant more like nitpicky with presentations and things that really don't matter in patient care in the big scheme of things. Like a couple of days ago, I was overhearing rounds from one of the teams, and the 3rd year resident and Attending calls out on the medical student for not having the appropriate "one liner"! I meant things like that that If I were in that Student's shoes would be deterred from Peds which is such a shame since we want to keep attracting Great students !

 

[LionInTheDark]

As a resident, I felt that one of my responsibilities to the medical students was to help them perfect their presentation skills. I did not, though, interrupt rounds to correct them. I preferred to mention things between patients or after rounds, generally in private. And they were always encouraged to give us feedback about how we could run things better.

However, the presentation is the primary means of communication about a patient among the entire team at a teaching hospital, and doctors minds are trained to process information in a certain way. Thus a disorganized presentation makes it harder to think through the case, and a streamlined, well organized presentation will help this thought process and also make rounds move alot faster. I think the one-liner is important to communicate to the team where you are going to go with your systems/problem based assessment and plan, and to let us know that you understand what is going on with the patient.

One caveat is that while I had high expectations for our medical students, I always sat them down on the first day and went through what I wanted to hear in a presentation, and what the attendings would probably ask for if not provided (ex. output from all orifaces/ostomies and change in weight on the peds GI service). Usually presentations were tight and well done after 3-4 days on a service.

Just one opinion from the other side...

 

[michigangirl]

As a resident, I felt that one of my responsibilities to the medical students was to help them perfect their presentation skills. I did not, though, interrupt rounds to correct them. I preferred to mention things between patients or after rounds, generally in private. And they were always encouraged to give us feedback about how we could run things better.

However, the presentation is the primary means of communication about a patient among the entire team at a teaching hospital, and doctors minds are trained to process information in a certain way. Thus a disorganized presentation makes it harder to think through the case, and a streamlined, well organized presentation will help this thought process and also make rounds move alot faster. I think the one-liner is important to communicate to the team where you are going to go with your systems/problem based assessment and plan, and to let us know that you understand what is going on with the patient.

One caveat is that while I had high expectations for our medical students, I always sat them down on the first day and went through what I wanted to hear in a presentation, and what the attendings would probably ask for if not provided (ex. output from all orifaces/ostomies and change in weight on the peds GI service). Usually presentations were tight and well done after 3-4 days on a service.

Just one opinion from the other side...

Ditto. Efficient presentations are one of the hallmarks of medical student education, and will serve you well for the rest of your career, no matter what field you choose. Students and residents need to learn how to present a large amount of information in a limited amount of time while making sure no IMPORTANT details are missed. The initial "one-liner" is not to be underemphasized. On a surgical rotation, the one-liner is even more important, because heck, that might be the bulk of your presentation, i.e., 57 year old African-american female POD 3 from partial colectomy" -- on a peds rotation, "SB is a 2 year old female admitted 4 days ago for failure to thrive now with concern for non-accidental trauma."-- these one-liners/summary statements set the stage for the rest of your presentation, and peds and IM rotations are two of the only rotations where there is actually TIME to focus on your presentations, which will serve you well in all of your other rotations.

Now, as Lion stated, it's the senior/fellow/attendings job to set expectations from the get go and teach you how to give an efficient presentation/how they like presentations from the beginning. Noone should be yelling at anyone on rounds-- but if you don't give a one liner at the beginning, I will stop you for a sec and politely say "can you give us a quick one liner for the group?"- won't let you move on without it. Any given day there are new staff on rounds on the floor or in the ICU's-- residents/pharmacists/nutritionists/social work/child life, you name it. They are all entitled to appropriate info and summaries.

 

[BigRedBeta]

I wouldn't call nitpicking presentations or notes passive aggressive.

Presentations and notes are some of the limited opportunities that I get to see how the medical students or interns are thinking. I'm far less impressed by encyclopedic knowledge than I am about being able to think through a new or unusual disease process. While it may not seem like it affects patient care, at a teaching institution my job as an upper level resident is not just to my patients but also into developing those younger than me into competent physicians. Particularly early on in the M3 year (and even for the M4's on their sub/acting internships), there is an acute need to push students towards being more efficient, organized, and concise.

This fits in with the RIME model of adult learning/medical education. The more encouragement to move out of the reporter mode, the sooner the student/intern/resident will begin to develop their skills as an interpreter of the data that goes into a patient. This is not only a benefit of them on their peds rotations but in any other area of the hospital. I'm well aware that not everyone wants to be a pediatrician, and while I make sure that students know that even if they end up being neurosurgeons or geriatricians or what have you, their patients are 1) going to ask them questions about kids or grandkids' health issues or 2) may have some sort of significant pediatric medical history that will in fact matter to the care they provide. But far more important than than those things is that I'm developing skills in them now that will make them better and more effective interns later on.

I also think it's important to hone in on the details because they do matter, although it's up to the teachers to demonstrate why those details matter or the thinking behind them. It's sounds strange, but it's pretty easy to "fake" your way through medicine. If ______ then do _______, without any understanding of why you're doing what you're doing. The details are the keys...why does the asthmatic child on continuous albuterol need q6 or q8 hour BMP's? What's the real effect of starting Zantac for a baby that refluxes? The answers may seem self-evident if you have enough experience but a full discussion of those answers reveals an extensive amount of nuance, and has significant implications on what you tell families, how you adjust your therapy and what you'd do next if things don't go the way you plan. But for the third year student or new intern who sees these patients, it's not infrequent to hear them offer up plans that include stopping the BMP's yet going up on the dose of albuterol (or glossing over the potassium level that's steadily been trending down), or wanting to change the Zantac to Prevacid "because the baby's still spitting up, so it must not be working"...

 

[Sweet Tea]

I had a big long reply, but I'm pretty much just going to echo what BRB said. So yeah. What he said.

 

[turkeyjerky]

I agree with the need for students to be able to formulate concise, well-thought presentations that include any pertinent details. But, on peds, it seemed like there was an obsessive focus on the "one-liner". Seemed like every day I was corrected on what to say, even though most of the time it was re-wording my sentence. Hell, even when I gave a good one the attending would interrupt to point out it was a good summary statement. I just don't get it, who cares so much about the oral presentation? Teaching actual pediatric medicine should really take precedence, but it was almost always crowded out by critiquing presentations or talking about what antibiotic was the best tasting.

You guys really do turn off a lot of students with this stuff, you know.

 

[michigangirl]

I agree with the need for students to be able to formulate concise, well-thought presentations that include any pertinent details. But, on peds, it seemed like there was an obsessive focus on the "one-liner". Seemed like every day I was corrected on what to say, even though most of the time it was re-wording my sentence. Hell, even when I gave a good one the attending would interrupt to point out it was a good summary statement. I just don't get it, who cares so much about the oral presentation? Teaching actual pediatric medicine should really take precedence, but it was almost always crowded out by critiquing presentations or talking about what antibiotic was the best tasting.

You guys really do turn off a lot of students with this stuff, you know.

Have you read any of the replies above to the original post? If you're turned off by this stuff, then pediatrics is just not for you. Consider yourself lucky to have narrowed down the list. There is a method to our madness-- and the oral presentation is a major part of internal medicine and pediatrics. What antibiotic is the best tasting is not trivial-- if you are sending a 3 year old home to finish an antibioitic course for a raging cellulitis that you started treating IV in the hospital, you need to know the kid is going to actually take it for the parent at home. That is one small pearl in teaching pediatric medicine. Be humble and just soak up whatever your teachers teach you.

 

[turkeyjerky]

Have you read any of the replies above to the original post? If you're turned off by this stuff, then pediatrics is just not for you. Consider yourself lucky to have narrowed down the list. There is a method to our madness-- and the oral presentation is a major part of internal medicine and pediatrics. What antibiotic is the best tasting is not trivial-- if you are sending a 3 year old home to finish an antibioitic course for a raging cellulitis that you started treating IV in the hospital, you need to know the kid is going to actually take it for the parent at home. That is one small pearl in teaching pediatric medicine. Be humble and just soak up whatever your teachers teach you.

It's so interesting that the attitude seems ubiquitous in peds. Have fun checking your thrice daily CRPs.

 

[michigangirl]

It's so interesting that the attitude seems ubiquitous in peds. Have fun checking your thrice daily CRPs.

I will, thanks! Once daily is good enough for me, though. And if YOU said you wanted to check them thrice daily, I'd ask you why. Call me passive aggressive!

 

[McGillGrad]

I agree with the need for students to be able to formulate concise, well-thought presentations that include any pertinent details. But, on peds, it seemed like there was an obsessive focus on the "one-liner". Seemed like every day I was corrected on what to say, even though most of the time it was re-wording my sentence. Hell, even when I gave a good one the attending would interrupt to point out it was a good summary statement. I just don't get it, who cares so much about the oral presentation? Teaching actual pediatric medicine should really take precedence, but it was almost always crowded out by critiquing presentations or talking about what antibiotic was the best tasting.

You guys really do turn off a lot of students with this stuff, you know.

With hours being cut and night float becoming the norm in medicine, your handovers will be as important as the "actual pediatric medicine" that you mentioned.

Teaching how to expertly relay info to the next team is a possible reason why they rework the words. Words, and how they are ordered in a sentence, are more important than you would ever imagine.

As for CRP, they should be using that for adult medicine, too. It is very useful.

 

[BigRedBeta]

I agree with the need for students to be able to formulate concise, well-thought presentations that include any pertinent details. But, on peds, it seemed like there was an obsessive focus on the "one-liner". Seemed like every day I was corrected on what to say, even though most of the time it was re-wording my sentence. Hell, even when I gave a good one the attending would interrupt to point out it was a good summary statement. I just don't get it, who cares so much about the oral presentation? Teaching actual pediatric medicine should really take precedence, but it was almost always crowded out by critiquing presentations or talking about what antibiotic was the best tasting.

You guys really do turn off a lot of students with this stuff, you know.

It's funny you say this. I've spent the last month on elective with our pediatric surgeons and the truth is, they simply throw the general surgery, transitional years, prelim anesthesia residents and third year med students rotating through on their service out into the deep end. They offer zero teaching on presentations and ruthless critiques. At least the pediatricians are trying to teach...

Further, the fact of the matter is that I have to have realistic expectations of what sort of pediatric medicine is actually useful for someone not going into pediatrics. I could teach you all sorts of variations of reflux, failure to thrive, bronchiolitis, and otitis media. But what is actually going to be useful? For the most part, individuals going into adult medicine fields are going to throw up their hands in surrender the moment a sick child gets placed in front of them (which to some extent I find hilarious given the stereotype that peds is for non-competitive/bottom of the barrel med students). I would love to spend hours teaching the sorts of things that excite me about taking care of children. I'd love to talk about illnesses that occur in the NICU, severe asthma, DKA and congenital heard disease but in the end, my goal - when it comes to pediatric "medicine" - really has to be to prove the point that children are not just little adults, how to recognize "sick" kids that need immediate intervention, and to give some sort of insight into what sort of things get tested on the shelf. Beyond those things, students are going to get more out of my teaching if I focus on skills that are broadly applicable.

Lastly, while it doesn't seem that way on SDN, I know (and the data supports it) that Pediatrics is the 2nd most popular specialty in the match. I believe there are very few people who come in thinking they'll be pediatricians that change their mind because of the way pediatricians teach, because in the end you either like taking care of kids or you don't. I always tell students that when you get right down to it, they have to focus on the actual medicine, not who their attendings or residents are but on what they'll actually do as a physician in that field. Anyone who bases their decision on who they worked with or how they were treated misses the point. If you love the OR, then do something that will put you in the OR. If you love the pace and types of problems that occur in clinic, then don't go into a field where you have to do inpatient care. People, friends and mentors come and go but the medicine/care stays constant and that's what students need to make their decisions on.

 

[Sweet Tea]

I agree with the need for students to be able to formulate concise, well-thought presentations that include any pertinent details. But, on peds, it seemed like there was an obsessive focus on the "one-liner". Seemed like every day I was corrected on what to say, even though most of the time it was re-wording my sentence. Hell, even when I gave a good one the attending would interrupt to point out it was a good summary statement. I just don't get it, who cares so much about the oral presentation? Teaching actual pediatric medicine should really take precedence, but it was almost always crowded out by critiquing presentations or talking about what antibiotic was the best tasting.

You guys really do turn off a lot of students with this stuff, you know.

I admit to hounding my students about the "one-liner". At least (and this is a conscious attempt to avoid "read-my-mind" questions) I tell them on the first day that I expect a one-line assessment after the subjective/objective and before the plan on every single patient they present. I have several reasons for this, but my main one is that I realize that we in peds tend to be a bit anal retentive and that there are a lot of details that we care about more than our adult counterparts. But with the one-liner, it lets me know that the student hasn't gotten lost in the details, remembers why the patient is in the hospital in the first place, and where they are on the path to going home. It also helps the students just get used to quickly relaying the important information. Like michigangirl said, with the new work hours rules and the numerous sign-outs that occur daily, this is going to become the vital to medical communication.

Regardless, you sound frustrated with your rotation. At both my medical school and my residency program, students were encouraged (and expected) to find their intern before rounds and review the salient points of their presentation with them. This serves several purposes: it gives the intern a heads-up that you're seeing the patient (it's amazing how often students and interns pass like ships in the night on the same patient), it lets the intern critique the student's presentation away from rounds so that you get the important points and can weed out the unimportant points, and it lets the intern fill the student in on things that have happened since they rounded (thus avoiding the med student lab sabotage, when labs come back after the student has pre-rounded at ***** o'clock). This in turn helps rounds go more smoothly, the med students look good b/c their presentations are sharp, the interns look good b/c the med students are doing well, and the seniors look good b/c their team is running well. And rounds go faster...everyone wins! So long story short, maybe you should try to track down your intern before rounds and quickly run through your patients.

 

[turkeyjerky]

Man, it's really amazing to me that pediatricians everywhere have such a focus on oral presentations and one-liners. I really would've expected much more institutional difference.

For the most part, individuals going into adult medicine fields are going to throw up their hands in surrender the moment a sick child gets placed in front of them...I'd love to talk about illnesses that occur in the NICU, severe asthma, DKA and congenital heard disease but in the end, my goal - when it comes to pediatric "medicine" - really has to be to prove the point that children are not just little adults, how to recognize "sick" kids that need immediate intervention, and to give some sort of insight into what sort of things get tested on the shelf.

This is what I don't get. The whole focus of you guys seems to be on teaching that "kids aren't just little adults" and leaving it at that. As someone who will be treating children in the future, I did want to learn about actual pediatric medicine. I would've loved some lectures on DKA, neonatal resuscitation, initial workup/management of CHD. Maybe the reason most people are only able to throw up their hands when they see a sick kid is b/c the only thing they were taught on their pediatric rotation is how to give a good summary statement. "This is a previously healthy 1 month old male, full term, who is DYING."

(For the record I did my peds rotation 6 months ago and got honors--it was a decent rotation overall, but the rounding was definitely frustrating as hell.)

 

[oldbearprofessor]

I would've loved some lectures on ......neonatal resuscitation,

Really? There's a CD you can buy that explains NRP way better than I can in any lecture, whether it's in a classroom or at the bedside. Now, simulation beats that, but sim center training isn't a lecture which is what you asked for.

Sorry you didn't like your pediatric teaching, but I doubt that more lectures would be the way to improve a pedi core rotation. Mostly there are too many of those in my view.

I also hope you gave meaningful anonymous feedback about your complaints to the core rotation director.

Be well and become a better teacher than the ones you didn't like. But, I really doubt that more lectures are the way to improve a core rotation.

 

[Sweet Tea]

What OBP said.

It sounds like the stuff you're interested in like DKA, management of CHD, and NRP is stuff that's more suited to pediatric specialties and not part of the core curriculum. But these topics make for great bedside learning during your fourth year sub-internships.

And it's amazing the number of kids you see that get transferred in from adult-care facilities that are dying an no one has realized it. So yeah, if someone can say "Hey, this kid is dying", then that's a success.

 

[turkeyjerky]

Really? There's a CD you can buy that explains NRP way better than I can in any lecture, whether it's in a classroom or at the bedside. Now, simulation beats that, but sim center training isn't a lecture which is what you asked for.

Sorry you didn't like your pediatric teaching, but I doubt that more lectures would be the way to improve a pedi core rotation. Mostly there are too many of those in my view.

I also hope you gave meaningful anonymous feedback about your complaints to the core rotation director.

Be well and become a better teacher than the ones you didn't like. But, I really doubt that more lectures are the way to improve a core rotation.

Those were just the first three topics that came to mind, and by lectures, I really meant bedside teaching or mini-talks. (Although I don't quite get the vehement anti-lecture bias that seems in vogue these days).

Not sure what is in the "core" curriculum then, is it limited to which antibiotics taste good, vaccine schedules and how to correctly change "poopy" diapers with your bare hands? Obviously my interests are biased by my future specialty, but don't you agree that some medical topics are also worth learning about?

 

[McGillGrad]

Those were just the first three topics that came to mind, and by lectures, I really meant bedside teaching or mini-talks. (Although I don't quite get the vehement anti-lecture bias that seems in vogue these days).

Not sure what is in the "core" curriculum then, is it limited to which antibiotics taste good, vaccine schedules and how to correctly change "poopy" diapers with your bare hands? Obviously my interests are biased by my future specialty, but don't you agree that some medical topics are also worth learning about?

I agree that it sounds like you got a raw deal in your rotation. Peds should be one of the best teaching experiences in 3rd year.

It is an absolute RIGHT for med students to have an alien medical speciality (which is weakly taught in basic sciences) explained thoroughly for purposes of shelf exams and future reference.

I would say your experience was crappy, not peds residents, in general.