An ongoing dialogue on HIV/AIDS, infectious diseases,
June 23rd, 2019
Advice to Incoming Subspecialty Fellows — Don’t Underestimate or Belittle Your Interns and Residents
An Unsmart Bulb (Photo by Ashes Sitoula on Unsplash)
Around a million years ago, early during the first year of my ID fellowship, a medical intern consulted me about an elderly patient with a urinary tract infection.
Me: Does she have a catheter?
Intern: I don’t know.
Me: Has she been admitted before with a UTI? Any cultures?
Intern: I think so — wait, I’m not sure. Let me check her chart.
Me (testy): Nevermind — we’ll come by and see her. (Slams down phone.)
It might have been a busy day for me. Or a late afternoon consult. For whatever reason, I was feeling pretty fried.
Over the next week, I channeled my frustration with this exchange by citing it several times as an example of the general cluelessness of the current interns and residents — house staff at the very fine hospital that kindly had accepted me to their fellowship.
But wait. That can’t be right.
Indeed, let the record show that I was emphatically wrong — the interns and residents during my fellowship were outstanding. This particular intern had a PhD in immunology and was just getting started as a doctor. No surprise that not all the details were immediately at her fingertips.
I bring this up today because right now, in many teaching hospitals, the interns have already begun, and the subspecialty fellows are waiting in the wings. Most start in the next week or so.
It’s therefore a perfect time to take on this commonly held (and sometimes, alas, openly voiced) opinion by some subspecialty fellows as they grow into their new roles:
These interns and residents are weak!
There are numerous triggers to this ungenerous thought. Most involve consults deemed “inappropriate” by the subspecialty fellow, for a variety of reasons:
- Consult called without having complete information. (My example.)
- Consult called without asking the right question. (How can they always know the right question if they need help on a case?)
- Consult called “too early” in the admission, without the house staff doing the full initial work-up.
- Consult called “too late” in the admission, with the house staff mismanaging the case before calling the consult. (Look how the residents can’t win here, with both #3 and #4 suggesting some magical precise correct time for calling a consult.)
- Consult called too late in the day.
- Consult called by the medical student, which is deemed insulting to the newly minted fellow. (Oh come on.)
- Consult called for something the fellow would have handled without a consult when they were residents.
I bolded this last one since it’s probably the most common example. (Junior faculty sometimes succumb to this one as well. It’s an early form of, “In my day …”) What weakness!
So let me emphasize, again, by noting, emphatically, that this perception is a total illusion.
There is zero evidence that interns and residents are weaker, less thoughtful about patient care, and less thorough than we were during residency, whenever and wherever that may have been.
How do I know? Because there’s a control group — those who do their fellowships in the same hospital as their residency. These fellows sometimes cite weakness in residents who were, until very recently, their colleagues. And folks, it’s literally impossible that suddenly and unexpectedly, the entire house staff regressed, losing all their clinical skills when said fellow graduated.
So what’s behind this negative line of thought? And what can we do to correct it?
To answer these questions, a few months ago I posted the following:
Residents are never as good today as they were when we trained, and also never as good as hospital X than they are where we did our residency, wherever that might have been.
This isn't true, of course–so why are these views nearly universal? And what can we do about it?
— Paul Sax (@PaulSaxMD) April 20, 2019
Encouragingly, many responded that they feel that today’s house staff are wonderful.
But some acknowledged that the phenomenon exists, and offered various thoughts about its origins. I like this response, from ID colleague Dr. Andrej Spec (who may be better known on ID Twitter as @FungalDoc):
Nostalgia. That, and as we get better, it becomes easier to see the mistakes that we were oblivious to previously. The solution is to keep remembering the times we made mistakes. So that we put ourselves in perspective.
Or, from a rheumatologist (@Doctorkuch):
Thinking that everything you know now, you knew then (false!). #constantlylearning
These comments get right to the heart of the problem. We spend the years of residency honing our craft, becoming better at what we do through clinical experience, teaching conferences, and reading. By the time we are in our last year of residency, there’s a wonderful sense of mastery — that’s the good part.
The bad part is that we may unfairly expect similar mastery from our junior trainees.
So the next time we feel like criticizing an intern or resident for not having all the information, or not consulting at the right time, or calling a consult on a case we think we would have handled ourselves without a consult — remember what it was like to start your training.
And remember, this doctoring thing is hard — a lifelong exercise in learning, and trying to get better.
It may not be quite as difficult as getting this “smart” light bulb to work, but it’s close.
So how many ID docs does it take to change a light bulb?
12 Responses to “Advice to Incoming Subspecialty Fellows — Don’t Underestimate or Belittle Your Interns and Residents”
Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
Biography | Disclosures | Summaries
Learn more about HIV and ID Observations.
NEJM Journal Watch — Recent Infectious Disease Articles- When it Comes to Antimicrobial Stewardship, Is a Boost Better Than a Nudge?
- HIV Prevention and Treatment: Updated Recommendations from the International AIDS Society–USA
- Observations from ID and Beyond: Dr. Thomas O'Brien — Expert in Antimicrobial Resistance and Giant in His Field (Literally)
- How Serious Is Artemisinin Partial Resistance in African Malaria Parasites?
- Observations from ID and Beyond: Who's Going to Get Lenacapavir for HIV Prevention?
Agree with above, but …
It goes both ways. The “inappropriate” criteria mentioned don’t make consults really inappropriate, but some of these things are best avoided by the housestaff. For example, I don’t mind a call from the med student – really I don’t – but the resident owes it to the student, me, and the patient to prep the student so he or she will be able to present the issue to me in a coherent fashion.
Every generation thinks the next is going to hell in a handbasket. There was a time when people thought Elvis meant the end of civilization. Yeah, the millenials are different from my generation (baby boomers); in some ways better, in some worse, but whining won’t fix anything. I try to avoid harsh criticism except in the most egregious cases, usually laziness. But if they call me without having devoted some thought to the question, they can expect to be dragged socratically through the logic of the case until they come up with something.
In any case, at my age I had better be nice to trainees, and do my best to educate them, since in a few years they will probably be taking care of me.
Jon Blum
As a reality check, I often think about what I would do if it were my responsibility to care for someone presenting with an acute myocardial infarction and imagine my unsophisticated questions for the cardiology consultant…!
As a residency director, I applaud your passionate defense of Internal Medicine house staff. We’ve all heard the same rants about the “younger generation” of physicians and how their overall mental acuity, work ethic, physical exam skills are dwarfed in comparison to their attendings and subspecialty fellows (all falsehoods, based on 30 + years of experience).
Here’s a piece from JAMA written by Gurpreet Dhaliwal, who strongly supports your assertions.
https://jamanetwork.com/journals/jama/article-abstract/2474428
Randy
Wow, that GE video is a doozy. Are they still in business?
Too good to be true, I would say.
Also, I would say doctor, as a profession, is overrated. I am telling this being a medical student myself.
Interns & Residents are there for the training.. so train & not degrade them.
I have three rules as a consultant:
1. Always be helpful. Your examples of “inappropriate” consults are just opportunities to be helpful by educating and guiding the requestor, regardless of level of training or seniority, not just new housestaff.
2. Always answer the question asked in the consult. Even if you don’t think this is the most important problem, it was the question that prompted the consult.
3. Never only answer the question asked in the consult. Always look at the complete patient – there may be other, more important issues in the consultant’s field that should be addressed.
Speaking as a mature medical student… it is really hard to develop any skill to be “ready“ at the level everyone wants you to be when you’re an intern. That’s because as soon as a medical student (here in Australia) tries to step up and take responsibility and do things they are often treated with impatience and dismissed by registrars, residents and interns. Very few hospital staff has any leadership skill to effectively mentor junior doctors and students- the behaviour you mention is a symptom if this.
I am a PGY-25 this year.
I cope with perceived ineptitude in three ways.
One, it is good for business and part of the “available, affable and able” A’s of being a consultant that is oft quoted when we neurotic ID people worry too much about how we are being perceived (it does not help that some people add the “appearance” A to the list – I hope it does not matter too much what I look like when doing consults for VRE in the urine). anyone who was ever in private practice lived (or died) by these rules.
Two, I recognize that ID people are considered “experts” in the most basic of skills: we talk to patients, we exam them, we look at labs and x-rays and plates ourselves. In today’s electronic gadget enabled medicine, this is a skill set that we have that others (especially ED personnel) do not have. It is especially important to have mastery of the fundamentals, which the new people often do not.
Thirdly, it is so easy consult on a relatively simple case than on, say, a severe meningococcemia, so I am happy to assist on those cases that cause little to no “ID stressors” than ones that do.
I hope when I am a PGY-35, I am just as good to the PGY 1’s as I try to be now.
Thanks for (as always) a great post Paul. Looking back at my fellowship years, I have a handful of clinical regrets but many more about how I interacted with colleagues. Respected attendings modeling behavior like this is a great start, but more focus also needs to be paid to the fellows themselves; not just constant, constructive feedback but also recognizing with compassion that, while attendings may be on for 2 weeks at a time, at least at my fellowship, fellows had 40 weeks of consults their first year. Alternative models that build more collaborative interactions and allow us to do the teaching that we love, such as embedding fellows in to a medical or surgical unit, could be tried. And, as much as possible while preserving case volume and learning, decreasing the punishing unpredictability of fellowship would allow all of us (I think) fundamentally kind people to actually be kind in the moment.
Excellent point, Jake. First year of fellowship can be relentless, and it’s one of our responsibilities as attendings never to forget this — and to provide the necessary support.
-Paul
Medicine is hard enough without being treated poorly . Nice reminder that we all need civility among peers. It is OK to correct younger colleague ; for example in the case given it is ok to tell the medical student to check for Foley to check the labs and then call you back. Then you’re teaching but not belittling.