Potential low pass on rotation - what should I do.

[Medshpep2021]

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[Skarl]

She paused and said that she really didn't feel safe with me taking care of patients and it could be a detriment giving me anything higher. I asked what makes her think that and she said that aside from the first two weeks (asking too many questions, communication issues), she thinks that I have caught up for clinical knowledge but also I still need to work on history/note taking. More importantly, there were instances (which I really cannot remember when) where patients felt uncomfortable with me when I was introducing myself before going into the OR because I just stood there and didn't talk. I was really shocked

In all honesty, it sounds like working on your social skills and being more strategic could be helpful. Some experiences on clinicals are definitely frustrating and unfair, like having your time not valued or inconsistent evaluations. But if your clerkship director, who has presumably evaluated many students at your school, expressed concerns about your competency and patients feeling uncomfortable around you, it suggests areas for improvement in your clinical skills and self-awareness.

Also, succeeding on clinicals is like a game and playing it well can be crucial to success. For instance some things I noticed in your post:

1. When you reached out to the dean because you feared failing the clerkship, your clerkship director may have perceived it as you going behind her back to escalate the issue.
2. It's important to be personable and charismatic with patients even as a student. In general you should always introduce yourself, project confidence, and try to get to know your patients. Obviously you're not leading conversations, but there are many ways to do this. Especially in surgery a lot of communication is nonverbal, and you can show engagement/enthusiasm even through just body language.
3. Being on time and asking for help is the minimum expected. And going the extra mile and precharting can go unnoticed if you don't make it known. Ask questions that show you've done your reading during cases.
4. While it's great to focus on positive patient encounters, it's important to recognize that patients/preceptors won't necessarily always tell you if they don't like you or had a poor experience. Learn from this setback and work on self improvement as your dean advised.

 

[Dral]

I agree with the things Skarl mentioned. I can sympathize. I had a less than optimal research experience with a surgeon when I was a student. He graded me pretty harshly and stuck to his guns. Dude actually gave me a 'D' for a research rotation. I felt like it was more to prove some point than to reflect the work I actually did, but I didn't feel it was worth arguing it so I just moved on. In the end, it didn't affect anything and I still got into the specialty I was aiming for (a competitive one). So I know you're stuck in the moment right now, but this may affect you less than you think in the end.

If I remember your other thread, you were the one who tried to correct the attending. I really think that's one of your big mistakes tbh (and ties in with what Skarl is saying). I hate to say that, but I think it's true here. I will ALWAYS recommend anyone correcting an attending if it's a concern of direct patient safety (Dr. so and so, I believe it's actually the patient's left kidney, not the right one we're about to be working on). But a medical knowledge correction is a little different. We are all in pursuit of correct knowledge, but part of what we do is knowing when to stay quiet about things as well.

In that situation, your 'correcting' the attending doesn't change anything. When you step back and think about it, you could have a positive outcome where the attending is super understanding and says "Ok, you're correct, thank you. What wonderful knowledge you have as a student". More than likely though, the attending is going to be correct or they will feel embarrassed that a medical student corrected them in front of everyone.

If you really felt the need, you should have gone to them later in private and said "I felt differently about that anatomy. Could we review it again?". Even THAT could be taken as an 'attack' on the attending's knowledge. The attending thinks to themselves "Oh, YOU felt differently. So you are saying you know better than I!". So even better might be "I was unsure about that anatomy. Could we review it again?" Sure the anatomy on the patient is now covered up which is suboptimal, but it satisfies your curiosity and it lessens the possibility that you will piss the attending off.

 

[voxveritatisetlucis]

I really wouldn’t try guilting her “how would this affect my career.”

Doesn’t look great at all and could backfire

If you keep pushing she may just fail you entirely

 

[GoSpursGo]

Just do your best and try to get it up to a pass. And I agree, you need to at least put on the appearance of caring about the process of learning. There is nothing more annoying than the student who is just there to get the grade and move on, so I suspect asking about the "impact of your grade on your future career" did you no favors.

Finally, you really need to hear the feedback you are receiving. A clerkship director told you that she does not feel safe with you taking care of patients--that is some DAMNING feedback. Whether or not it is entirely fair is impossible to tell, but thinking back to all of these anecdotes of how a random attending said something nice to you or how you had a nice interaction with one patient is not evidence that the feedback is wrong. Again, you need to internalize the feedback and focus on the process of being the best medical student you can be every day and in every interaction. If you follow that process, then results including grades will follow, though perhaps not in time to salvage your grade in this rotation.

 

[Osminog]

Reading between the lines of this post and your prior one, I have gathered that you: asked too many questions and asked them at inappropriate times, texted attendings excessively, had a miscommunication regarding where you were supposed to be on at least one occasion (OR vs. outpatient), challenged attendings about medical knowledge that they quizzed you on, and made patients feel uncomfortable due to your awkward behavior.

First off, something about medical culture that you need to know is that it is extremely hierarchical. Many attending physicians are overconfident and conceited. After they finish their training, physicians enter privileged positions in which nobody can openly question their clinical judgment, except in cases of gross negligence; they are on top of the food chain, and everything they see and hear can only reinforce their beliefs and inflated self-images. As a medical student, you are at the bottom of the hierarchy. You are below nursing assistants and patient care technicians. You are not in a position to question attending physicians' medical knowledge—and when you do, you will always be perceived as out of line and unknowledgeable. When you ask questions excessively or at inappropriate times, you will also be viewed as out of line and unknowledgeable.

It sounds like you're a socially awkward, introverted person with low agreeableness. It also sounds like you're highly intelligent and motivated to succeed during your clinical rotations. You won't be able to magically transform your personality, but you can take the time to try to recognize your deficits and adapt accordingly. When you have the impulse to ask a question or challenge an attending's teaching point, stop and try to analyze the situation you're in—the specific social setting and your position on the hierarchy relative to that of the individual you're talking to. If ever in doubt, it's generally safe to not say anything and to just wait until the attending asks you if you have any questions. Sometimes medical students think they're being proactive and engaged, but they're really being perceived as annoying or argumentative.

A complicating factor here is that this is a surgery rotation. The culture of surgery is more hierarchical and conservative than the average medical specialty. Unless you receive explicit permission to do so, you cannot spontaneously blurt out questions during a surgery or during a patient encounter, nor can you ever challenge a surgeon's explanations. It sounds like you crossed some boundaries and pissed some people off along the way.

Finish strong. A "low pass" isn't going to make or break you. The best thing you can do is to learn from this experience and approach your future rotations with greater senses of caution and self-awareness.

 

[mrbreakfast]

You clerkship director telling you she doesn't feel safe with you taking care of patients is a full stop moment. It doesn't matter what other feedback you've gotten - in medical school you are far more likely to get positive but inaccurate feedback from people who don't want to hurt your feelings, or people who are too busy with other things to sit down with you, then anything constructive. When someone sits down and gives you criticism, you need to listen.

I agree with @Osminog in that I think you probably need to work on your "people skills," which is one of the most challenging things to improve - it's not something you can "study for." I'm concerned you're mistaking polite social interactions for positive feedback. To a degree, every medical student struggles with the most basic aspect of medicine - having a relaxing, disarming conversation with a patient while composing an accurate and concise history, and then presenting that to the attending. Some people struggle more than others. I am reminded of a medical student I worked with last year who was clearly oblivious to how uncomfortable he made patients, and who spent hours finding several citations of an esoteric medication interaction with coumadin, rather than just asking the patient how he takes the medication - his INR was off because he was taking it wrong.

Work hard, keep your head down, and treat your patients like you're talking to a twice-removed aunt - someone who's family but who you don't know very well. Do what you're told and speak when spoken to. Focus on salvaging this rotation, and then plan how you'll approach the next block differently.

 

[Tenk]

Attendings are people. We have families, lives, and other problems outside of this job. I get that you care about your grade but you clearly got on this persons bad side by pushing too hard. In the future, if you’re failing or doing bad, ask why once, listen, don’t make any excuses, nod your head, say you’ll do better and leave it at that. In this case, just try to pass, learn from this, and never do this again in the future.

 

[Rachapkis]

An old adage from the NCCA Basketball Tournament comets to mind: survive and advance. Some things will not go well and that's okay. Learn from them and try not to make the same mistake twice. The key is not to let them derail you--something that you will have accomplished if you receive a low pass.

 

[EmperorK]

So currently on my second to last day of my rotation as a followup to this thread (Worried about failing first rotation - thanks in advance for those who followed and gave me advice) - I did talk less for the remainder of the clerkship. I also talked to my clerkship preceptor about this three weeks back and she said she would followup with me every week (in her words, improvement is also part of the grade!) - this ended up being just one outpatient afternoon or one operation a week, and

So I'm glad you followed our advice. It seems from this post that things were worse than you posted so I'm going to address a few things.

she didn't really continue pimping or questioning me to gauge my knowledge when my UWorld/NBME/history taking skills were clearly improving.

Yes, she realized you were smart, but not the most socially adept person. That's why she stopped gauging your knowledge, I'm wondering if the issue with your note-taking skills was that they were irrelevant to what she needed. And you couldn't read that.

I also didn't receive a formal midclerkship feedback session until 5/6 weeks in (she kept saying for two weeks to look out for a email sometime in the next two days but never emailed until I finally emailed her last week). Told me she had time at night after work for a longer, more formal session but then texted me saying she was too tired.

I had an analogous situation with an anesthesiologist twice. Did u tell her it's okay because you know she's working hard? I did this and had an excellent relationship with her. Cause I made it clear that I understood where she was coming from. Think of it from her perspective, she has this socially awkward student, and now she must take more of her time to teach him how to people. That's hard.

I ended up skipping lunch twice between OR times to wait for her but that didn't work out as well as she had to run off 2 min into the session when her beeper rang and another time for a meeting. Finally, I had my mid clerkship meeting last Wednesday - which ended up being 10 min phone call in between two operations where my clerkship director called me out of the blue and really just readdressed concerns from the first two weeks.

Sounds to me like you probably either did more socially awkward things or ****ed it up so badly in the first two weeks that it was unsalvageable from that perspective. The feeling u get from seeing someone is hard to change.

We never really focused on anything from the recent few weeks, though she did say from outpatient encounters, she thinks I had improved a lot knowledge wise and knew better when to ask questions but still did have a lot to work on. In fear of failing the clerkship, I reached out to my school's dean - who scheduled a meeting with my clerkship director last Friday.

Great! Now my socially awkward student made me go to another meeting! I wonder why she's going to either fail you or give u a low pass.

Today, I met with my clerkship director again after her meeting with my dean and apparently she said she was most likely to give me a low pass (potentially a pass or a fail depending on how this week's evals and final presentation go). I said I understood and asked how she thought a low pass could affect my career. She paused and said that she really didn't feel safe with me taking care of patients and it could be a detriment giving me anything higher.

So she's saying you're socially awkward and that she might fail you. And you say how that will affect my career? I mean, not a good look. This is why she told you the second sentence. She doesn't feel safe with you at all, that's why she doesn't let you be around patients alone.

I asked what makes her think that and she said that aside from the first two weeks (asking too many questions, communication issues), she thinks that I have caught up for clinical knowledge but also I still need to work on history/note taking. More importantly, there were instances (which I really cannot remember when) where patients felt uncomfortable with me when I was introducing myself before going into the OR because I just stood there and didn't talk.

Let me tell you something. Patients (and simulation patients) tend to lie to your face and in front of your supervisor (I had this happen to me last week). So, what she is assessing is non-verbal cues that show discomfort. Could she be biased about you? Yes, absolutely. But you that's your fault for the first two weeks.

I also really think that I improved these past few weeks - had a surgeon who I worked with for three days total these past two weeks compliment me several times on my "profound clinical knowledge" and patient presentation skills and that he was sure I'd score 90+ on the shelf.

This is a very critical point in your post that says a lot about you. We've been discussing that you're smart, but not the most social. So why are you bringing up how smart you are when there are forty posts that tell you that's not the problem?

I am just really confused as to what actually is happening - just met with my dean tonight who pretty said the same stuff my clerkship director said and told me not to worry about my grade but focus on improvement since its my first clerkship and so I couldn't even really argue.

I have a feeling that the problem is more self-awareness or acceptance rather than understanding.

The fun part about this is that social skills are fixable. But it is painful and takes a while (6months to 5 years IMHO). But you can do it. I believe in you OP and if u need support, you can PM me. I'll be glad to help over discord.

 

[operaman]

Agreeing with others: the clerkship director saying they aren’t comfortable with you taking care of patients is huge. Nothing else you wrote really matters to be honest. You need to figure out why people aren’t comfortable with you caring for patients and fix that. Students who get told this are the ones who get dismissed in the clinical years, or if they’re lucky, as junior residents. It’s rare but it happens.

Reasons most likely are:

1) socially awkward, makes patients and staff uncomfortable

2) poor documentation and presentation. Missing key H&P elements. Nobody expects students to generate good plans because that takes years. I’m still working on that part even now. But they should be able to take a good relevant history, distill it down, and write a concise note and give a focused presentation. They should know how to do an exam and present it. You are missing key points in these areas.

3) self unawareness. Maybe goes under 1 above. But you don’t seem to understand how you’re perceived or how what you’re doing is read by others.

4) inability to take feedback. Even here in your post you rationalize everything away. Faculty rarely if ever tell students they aren’t comfortable with them caring for patients even in a supervised setting. That’s huge.

5) correcting attendings. Odds are you were wrong, and this just reinforces the self unawareness and inability to take feedback. Surgeons in particular go through a loooooong training process. That first year assistant professor surgery attending has been a doctor just as long as an internist who’s been an attending for 5 years (or more). Surgeons in academic settings have done 7-10 years of training post med school. It’s unlikely you’re going to be right when you correct them because even the noobs have 10 years of experience on you.

Those are the most likely issues I can think of. The low pass is the least of your worries. My gut says they are doing that because they don’t want the hassle of trying to fail you plus failing you means you just repeat the rotation. Your saving grace is that it’s early in the year, but if you don’t turn things around you may not graduate at all.

 

[Medshpep2021]

Thank you all for the feedback. I have thought about it again today and know it is hard to swallow but I really think the best step would be to accept all of this and move on.

I do imagine it is also hard from her perspective and at my final clerkship meeting later this week, I will just be brief, make no complaints, and admit that I have struggled in various ways (after all, she's seen so many students come and go) and make no mention of grading. I do really have a lot to work on and will try my best to improve on future clerkships.

 

[emergentmd]

You are overthinking this. This is not the end of the world. If you are confident you improved and there are no issues, take your grade and move on. If this never happen again, then its just a POS attending who has a miserable home life and brings it to work. You are just the punching bag which happens all the time. Even as an attending, you will meet unhappy people who will question your care.

If this happens again on another clerkship, then you really need to reflect and figure out what is going on.

It clearly is not your breadth of knowledge. In no way can anyone judge an M3 on their 1st rotation and come to the conclusion they are a danger/detriment to patient care. Impossible.

We all have been M3/M4, and I will tell you most M4s lack any reasonable medical knowledge/presentation skills. I have been a preceptor in the ER and the M4s going to EM barely even knew how to present a history.

Hell, R1s have almost zero patient care/clinical knowledge. I remember being an R1 on my 1st call and wasn't sure if the nurse could give tylenol to the Pt.

 

[pierty]

Agreeing with others: the clerkship director saying they aren’t comfortable with you taking care of patients is huge. Nothing else you wrote really matters to be honest. You need to figure out why people aren’t comfortable with you caring for patients and fix that. Students who get told this are the ones who get dismissed in the clinical years, or if they’re lucky, as junior residents. It’s rare but it happens.

Reasons most likely are:

1) socially awkward, makes patients and staff uncomfortable

2) poor documentation and presentation. Missing key H&P elements. Nobody expects students to generate good plans because that takes years. I’m still working on that part even now. But they should be able to take a good relevant history, distill it down, and write a concise note and give a focused presentation. They should know how to do an exam and present it. You are missing key points in these areas.

3) self unawareness. Maybe goes under 1 above. But you don’t seem to understand how you’re perceived or how what you’re doing is read by others.

4) inability to take feedback. Even here in your post you rationalize everything away. Faculty rarely if ever tell students they aren’t comfortable with them caring for patients even in a supervised setting. That’s huge.

5) correcting attendings. Odds are you were wrong, and this just reinforces the self unawareness and inability to take feedback. Surgeons in particular go through a loooooong training process. That first year assistant professor surgery attending has been a doctor just as long as an internist who’s been an attending for 5 years (or more). Surgeons in academic settings have done 7-10 years of training post med school. It’s unlikely you’re going to be right when you correct them because even the noobs have 10 years of experience on you.

Those are the most likely issues I can think of. The low pass is the least of your worries. My gut says they are doing that because they don’t want the hassle of trying to fail you plus failing you means you just repeat the rotation. Your saving grace is that it’s early in the year, but if you don’t turn things around you may not graduate at all.

It's OP's first rotation. We have no idea what kind of personality the one attending that evaluated them has had. This unnecessary and counter-productive dogpile is precisely what I was referring to in my last post.

Thank you all for the feedback. I have thought about it again today and know it is hard to swallow but I really think the best step would be to accept all of this and move on.

I do imagine it is also hard from her perspective and at my final clerkship meeting later this week, I will just be brief, make no complaints, and admit that I have struggled in various ways (after all, she's seen so many students come and go) and make no mention of grading. I do really have a lot to work on and will try my best to improve on future clerkships.

This is the best attitude to have moving forward, and shows that you've taken the first step toward building the maturity that will help you become a great doctor. You do not need to come forward with what you think your faults are - just ask them and listen intently, and thank them afterwards. If they ask you how you plan to proceed, you can respond with a productive plan forward. It is always better to focus on constructive steps and actions - both when reflecting on experiences as a mentee, and a mentor. Remember that when you are teaching others down the line.

The culture of the wards (especially surgery and the OR) is something very different from what you've experienced in your pre-clinical curriculum and likely in undergrad. If you view the experience as something to learn from and not a "drag" or a zero-sum game for clinical evaluations, you will improve very quickly. This improvement is not academically based - you won't be able to use spaced repetition questions or flash cards to have it happen. But experiences like this one - while I'm sorry it has occurred - can be used to improve very quickly if you are open to learning how.

You aren't a terrible student, and you aren't "hopeless" or on a track to failure. Next rotation, try to focus on learning the environment and culture of your workspace (both when interacting with the patients, and your colleagues). There is a "sweet spot" between knowing when to ask questions/show enthusiasm and when to be quiet and respectful with a smile (even if you are tired and not feeling great), and you will begin to acquire these skills over time.

Things will work out - I believe in you. Good luck

 

[TheRealBatmanMD]

Once I become an attending/resident, my criteria for evaluating a student is 1) Are they having fun?

If the answer to the above is yes, honors. Medical school is about learning and improvement. I'm not going to penalize someone for doing their job (being a student). Some people just take longer to get over a learning curve.

 

[Medshpep2021]

Update: Got a pass in the end!

 

[Angus Avagadro]

An old adage from the NCCA Basketball Tournament comets to mind: survive and advance. Some things will not go well and that's okay. Learn from them and try not to make the same mistake twice. The key is not to let them derail you--something that you will have accomplished if you receive a low pass.

As a wannabe basketball coach, I have used this analogy many times! Teaching high-school chemistry and coaching basketball was my backup to med school!

 

[LeaveNoTrace]

Update: Got a pass in the end!

Good.

I would honestly recommend seeing a therapist and seeing what they have to say. You might consider one that treats a lot of patients that have social difficulties; they might be able to shed light on your social issues and potentially offer you treatment for them.

Good luck. PM me if you'd like to talk.