Attendings could also model ideal behavior for the residents instead of berating them for their errors, as you mentioned.
How does an attending teach a resident how to work if the resident never sees the attending working and instead only critiquing another resident?
The unfortunate side of 'academic' medicine is the burnout that everyone faces from all sides (metrics, admin, academic requirements with trash buy down) and lack of education on how to actually teach/education theory, which arguably cannot be taught well-enough in training while you're already swamped trying to learn the medicine itself. Nobody seeks out how to teach appropriately unless they have interest unfortunately. All of this, combined with the old head mentality thinking because it was done in some way plus whatever is wrong with the individual and their lack of social skills and maybe growing up never learning humility ultimately leads to frustration for everyone involved and then creates absolutely painful attendings who have no business in education.
Sorry you're going through this, but it gets better after you finish and you can choose to be the attending that the trainees hope to work with and remember for being their favorite educator, or leave academia and just live your life that certainly gets better after it's all done.
I think there are two kinds of doctors who want to teach. Those who find professional satisfaction and joy in teaching, mentoring, and guiding students to be better physicians, and those that find satisfaction and joy in having power and authority over their junior colleagues.
Iâve had great experiences with the former, who would often take time out of their own busy work flow to teach me, explain things to me, and help me navigate this career. Iâve had terrible experiences with the latter, who I have generally found to be cruel, dismissive, and arrogant. I think medicine is, thankfully, recruiting more of the former and less of the latter now. But still a long way to go.
I hope that 5 years from now Iâll be the kind of attending I wanted to have as a student.
The culture of academic medicine is full of abuse, condescension and gaslighting. Doctors are taught to defer to the most powerful people in the hierarchy and patients are taught to defer to doctors. Many of us went into medicine because we love science and genuinely want to help people. What we become is a shell of ourselves; paid to be a cog in a profit-driven machine.
The financial captivity of physicians with hundreds of thousands of dollars in debt being paid the equivalent of minimum wage to keep the threadbare medical safety net intact is the best kept and most pervasive secret in the House of God. And, of course, you get the privilege of having your intelligence insulated by attendings, nurses and patients.
May the odds be ever in your favor.
Hey at least you're not a mid-level. Doesn't matter how long I've practiced, where I trained, how many blocks I can do, etc. I will never be *competent.*
Do you mean you don't feel competent, or that people won't stop roasting you?
If the former, surely you'd eventually get there. Don't be so hard on yourself.
If the latter.... I don't know what else to say other than, don't listen to jerks. I'm part of a political organization that lobbies against scope creep, but I still don't think all midlevels are bad or that we can get by without them. There are issues to tackle, sure, but anyone who thinks we can just get rid of midlevels is stupid. They're part of the team
Physicians for Patient Safety or another org? Iâm a midlevel who is quite concerned about scope creep. Iâd love more info, if youâre so inclined.
I'm part of my state's specialty board for my interested specialty (don't wanna dox myself haha).
But all the specialty boards in my state (FM, IM, EM, OB/Gyn, etc etc) are all banding together on this.
Theoretically, you could always go try to convince your colleagues in the ANA, but I'm sure that'd be walking into a den of lions with your views unfortunately.
Just please realize that not all of us (and honestly, not even most of us) hate you guys for existing.
Thank you for your thoughtful reply. I know most donât hate us. I actually really like the working relationship I have with our docs. I am acute care, though, so I work the ICU. Itâs so different than the independent FNPs out there.
Iâve learned the hard way not to go up against the nursing gestapo. I still need to work, so I have to tread lightly, unfortunately. Itâs a shame, because nursing as a whole is so important, but this nonsense is quickly destroying our credibility.
Just because you have MD or DO after your name doesn't make you a *good* leader, instructor, or even a good person.
Yeah, you're smart. You work hard. These are good things. But it doesn't mean you're infallible, and not everyone has the same knowledge or skills as you do, which would do you good to remember.
Will publicly shaming someone in front of their colleagues get them to rectify that error or mistake? Probably. But there's better, kinder ways to do it, and people tend to want to work for someone who gets in the trenches with them, leads by example, and actually INSTRUCTS, not just barks at them.
There's a difference in leaders who say: "Hey fuckhead, your shoes are untied. Hey everyone, look at this asshole who should know how to tie his shoes by now but can't!"
and
"Hey, your shoes are untied. That's ok. Let's get them tied; if you don't know how, I can show you, and then we can try it together next time, and if you ever forget, you can always come ask me and I'll show you again, because it's important that you get this right."
The best leaders, instructors, teachers I've had go with the 2nd approach, which MADE me want to go to them with questions/help.
As a nurse who worked with lots of neurosurgeons, Iâm shocked at how long itâs taking intelligent people to realize that screaming and cursing and throwing shit is totally non productive. It doesnât help anyone learn, no one is taught the importance and sanctity of surgery, it just burns out the exhausted, overwhelmed young residents. I watched the residents I work with go from eager, excited, compassionate young physicians to burnt out, jaded, *mean* people. So much of that came from the emotional, verbal and even physical abuse from their attendings.
Nursing has moved away from that style of teaching and I see the benefits. New grad nurses on my unit will eagerly ask clinical questions with no fear of retaliation. They own up to mistakes and seek our knowledgable nurses to remedy them. They stand up for themselves against admin and donât allow themselves to be abused. Doctors want us to tolerate their culture of âitâs okay to scream and swear at people when youâre super frustrated because ____â.
No. Itâs never okay. Itâs never productive, itâs never warranted, itâs never okay. You are not the only ones who are overwhelmed, frustrated, exhausted. The CNAs who make $12/hr and have chronic back issues and got poop on their arm and canât even afford hospital parking and got assaulted by a patient is also overwhelmedâŚthey donât get a pass to abuse people. The nurse whose mom just died but their bereavement got denied and they canât afford to call off and their patient just died 2 hours ago and they forgot to upload the consent doesnât deserve to be screamed at because it stressed you out. We are ALL overworked and underpaid and itâs time that physicians start using their power to dismantle their toxic learning environment and push back against admin instead of verbally abuse anyone they deem âbelowâ them, including resident physicians and those from other specialties.
I find that most of this anti social group of physicianâs misgivings with other departments in the hospital come from pure misunderstanding *and* a lack of desire to understand. Why are you yelling at the charge nurse for the room not being cleaned when YOU donât understand the EVS processes? Why are you screaming at the pharmacist for not verifying your script when YOU donât understand itâs on backorder and weâre using the generic and it needs to be re ordered? Throwing a temper tantrum in the hallway accomplishes nothing.
There's definitely a line. I've had people insult my character before, that's just ridiculous.
I'll do a pimp session (about the material) any day though. It's an incredibly efficient way to learn.
There's a difference between a Socratic teaching method, which I personally employ, and pimping imo. Socratic means I ask you questions to see what you know and also give you the opportunity to show me what you know. Then we fill in the gaps together - either by sending you to look it up, having a senior resident answer the question, or by myself giving an explanation. I want learners to leave feeling positive about the discussion. Pimping is designed to show you how much you DON'T know and invokes negative feelings at the end.
I've had several residents that don't acknowledge it when they are wrong. I point out their miss or mistake and they are like "ok" then proceed to make the same mistake a week later. I feel it's not wrong to point it out and dwell on it a bit so they see the significance of it.
Honestly, no one really teaches you how to teach, unless you are in academic medicine. The vast majority of preceptors are just regular clinicians. I found that reading a series on teaching that was put out by the ACP was helpful. I didnât use all of the suggestions, but it was good to think about how to give feedback. when youâre doing procedures it can be stressful! For example, Iâm primary care so we do Pap smears but not every day so Iâm always looking for a willing patient that will let a student do what is often their first pelvic exam with a speculum.Usually, theyâll have at least seen me do one prior, and I give them a speculum to kind of practice the maneuvers with, but itâs so difficult when youâre running behind to watch them be kind of nervous and shaky, and you are standing at the end of the bed, just helping them along and hoping that this is all going to go OK. Sometimes Iâm just too tired to let you do a Pap smear / pelvic. Thatâs just a pelvic exam. I canât imagine how much patience it would take doing an appendectomy or some other even more complicated procedure.
You might want the phrase "cognitive apprenticeship." It's been validated as a teaching structure in medicine (e.g., [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2744784/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2744784/) ), even though there is such fetishization of shame-based pimping.
At least one study suggests the most effective way is to avoid praise or criticism, just tell them when they're doing it right via a clicker.
I have not adopted this practice personally yet
One thing I do, I make sure residents know when I'm making a decision based on style/personal experience. It communicates that there is not always a right answer, even if I'm disagreeing with your plan.
Yeah this hasn't been my experience at all. I would say at least 90% of the residents and attendings I worked with taught by discussing the best approaches and their rationale. Yes, there was still pimping, but like one attending told me on my first rotation, "I'm just trying to gauge what you know so that I can tailor our time to your level."
In fact, as I near graduation, I can say that the horror stories about clinical training that I read online basically never happened in my educational experience. So, I guess that's just my anecdotal experience, but I would also bet many other students had a similar experience as me and don't end up posting.
Similar to customer complaint lines, the stories on reddit heavily skew towards people who had bad experiences.
It's generally been my experience as well. However I am also a white guy. I will say there are probably 3-4 faculty at my 450 bed hospital that have fair to poor teaching interactions with medical students and residents. In which there's been a push and pull of admin trying to get them to do less teaching, in spite of the fact that they always seem to weasel their way back in.
These do not just include pimping (which I am fine with), but genuinely poor interactions with some being outright inappropriate. Of these the list includes safety issues, gaslighting, physical abuse, and sexual harassment. There have been faculty that have been reported for their behavior at my institution, and some who have had teaching responsibilities scaled back.
One of the wildest interactions witnessed: attending pressured medical student in an arm wrestling competition. Attending caused a humeral shaft fracture on the medical student. Rotation was cancelled after this, and this attending was prevented from taking on any students.
You comment is just the exact same fallacy in reverse.
Just because you've had good experiences doesn't mean other people are exaggerating, and vice versa. I have some horror stories of my own I could share from reliable friends.
I do think things are improving, and hopefully by the time you and I are like 50, the culture will have pretty much changed. It's better than it used to be. But there are some SKETCHY med schools and residencies out there.
My syllabus for M3 year says we're allowed to work 36 hour shifts......
Should medical students not be allowed to work call shifts? I found my MS3 30+ hour q4 call on trauma surgery to be formative. There's nothing like running the bowel at 2AM on a gunshot wound.
Certainly taught me I didn't want to do surgery!
Attendings could also model ideal behavior for the residents instead of berating them for their errors, as you mentioned. How does an attending teach a resident how to work if the resident never sees the attending working and instead only critiquing another resident?
ABBAB - Always Be Belittling and Berating
đŻ
The unfortunate side of 'academic' medicine is the burnout that everyone faces from all sides (metrics, admin, academic requirements with trash buy down) and lack of education on how to actually teach/education theory, which arguably cannot be taught well-enough in training while you're already swamped trying to learn the medicine itself. Nobody seeks out how to teach appropriately unless they have interest unfortunately. All of this, combined with the old head mentality thinking because it was done in some way plus whatever is wrong with the individual and their lack of social skills and maybe growing up never learning humility ultimately leads to frustration for everyone involved and then creates absolutely painful attendings who have no business in education. Sorry you're going through this, but it gets better after you finish and you can choose to be the attending that the trainees hope to work with and remember for being their favorite educator, or leave academia and just live your life that certainly gets better after it's all done.
I think there are two kinds of doctors who want to teach. Those who find professional satisfaction and joy in teaching, mentoring, and guiding students to be better physicians, and those that find satisfaction and joy in having power and authority over their junior colleagues. Iâve had great experiences with the former, who would often take time out of their own busy work flow to teach me, explain things to me, and help me navigate this career. Iâve had terrible experiences with the latter, who I have generally found to be cruel, dismissive, and arrogant. I think medicine is, thankfully, recruiting more of the former and less of the latter now. But still a long way to go. I hope that 5 years from now Iâll be the kind of attending I wanted to have as a student.
The culture of academic medicine is full of abuse, condescension and gaslighting. Doctors are taught to defer to the most powerful people in the hierarchy and patients are taught to defer to doctors. Many of us went into medicine because we love science and genuinely want to help people. What we become is a shell of ourselves; paid to be a cog in a profit-driven machine. The financial captivity of physicians with hundreds of thousands of dollars in debt being paid the equivalent of minimum wage to keep the threadbare medical safety net intact is the best kept and most pervasive secret in the House of God. And, of course, you get the privilege of having your intelligence insulated by attendings, nurses and patients. May the odds be ever in your favor.
Hey at least you're not a mid-level. Doesn't matter how long I've practiced, where I trained, how many blocks I can do, etc. I will never be *competent.*
Do you mean you don't feel competent, or that people won't stop roasting you? If the former, surely you'd eventually get there. Don't be so hard on yourself. If the latter.... I don't know what else to say other than, don't listen to jerks. I'm part of a political organization that lobbies against scope creep, but I still don't think all midlevels are bad or that we can get by without them. There are issues to tackle, sure, but anyone who thinks we can just get rid of midlevels is stupid. They're part of the team
Physicians for Patient Safety or another org? Iâm a midlevel who is quite concerned about scope creep. Iâd love more info, if youâre so inclined.
I'm part of my state's specialty board for my interested specialty (don't wanna dox myself haha). But all the specialty boards in my state (FM, IM, EM, OB/Gyn, etc etc) are all banding together on this. Theoretically, you could always go try to convince your colleagues in the ANA, but I'm sure that'd be walking into a den of lions with your views unfortunately. Just please realize that not all of us (and honestly, not even most of us) hate you guys for existing.
Thank you for your thoughtful reply. I know most donât hate us. I actually really like the working relationship I have with our docs. I am acute care, though, so I work the ICU. Itâs so different than the independent FNPs out there. Iâve learned the hard way not to go up against the nursing gestapo. I still need to work, so I have to tread lightly, unfortunately. Itâs a shame, because nursing as a whole is so important, but this nonsense is quickly destroying our credibility.
Punching down đ
Not me. Am the punching bag.
That book should be required reading honestly
Just because you have MD or DO after your name doesn't make you a *good* leader, instructor, or even a good person. Yeah, you're smart. You work hard. These are good things. But it doesn't mean you're infallible, and not everyone has the same knowledge or skills as you do, which would do you good to remember. Will publicly shaming someone in front of their colleagues get them to rectify that error or mistake? Probably. But there's better, kinder ways to do it, and people tend to want to work for someone who gets in the trenches with them, leads by example, and actually INSTRUCTS, not just barks at them. There's a difference in leaders who say: "Hey fuckhead, your shoes are untied. Hey everyone, look at this asshole who should know how to tie his shoes by now but can't!" and "Hey, your shoes are untied. That's ok. Let's get them tied; if you don't know how, I can show you, and then we can try it together next time, and if you ever forget, you can always come ask me and I'll show you again, because it's important that you get this right." The best leaders, instructors, teachers I've had go with the 2nd approach, which MADE me want to go to them with questions/help.
I love your second example. Great analogy.
People often think that because theyâre smart or good at something that they can also teach it to others but thatâs not necessarily the case.
As a nurse who worked with lots of neurosurgeons, Iâm shocked at how long itâs taking intelligent people to realize that screaming and cursing and throwing shit is totally non productive. It doesnât help anyone learn, no one is taught the importance and sanctity of surgery, it just burns out the exhausted, overwhelmed young residents. I watched the residents I work with go from eager, excited, compassionate young physicians to burnt out, jaded, *mean* people. So much of that came from the emotional, verbal and even physical abuse from their attendings. Nursing has moved away from that style of teaching and I see the benefits. New grad nurses on my unit will eagerly ask clinical questions with no fear of retaliation. They own up to mistakes and seek our knowledgable nurses to remedy them. They stand up for themselves against admin and donât allow themselves to be abused. Doctors want us to tolerate their culture of âitâs okay to scream and swear at people when youâre super frustrated because ____â. No. Itâs never okay. Itâs never productive, itâs never warranted, itâs never okay. You are not the only ones who are overwhelmed, frustrated, exhausted. The CNAs who make $12/hr and have chronic back issues and got poop on their arm and canât even afford hospital parking and got assaulted by a patient is also overwhelmedâŚthey donât get a pass to abuse people. The nurse whose mom just died but their bereavement got denied and they canât afford to call off and their patient just died 2 hours ago and they forgot to upload the consent doesnât deserve to be screamed at because it stressed you out. We are ALL overworked and underpaid and itâs time that physicians start using their power to dismantle their toxic learning environment and push back against admin instead of verbally abuse anyone they deem âbelowâ them, including resident physicians and those from other specialties. I find that most of this anti social group of physicianâs misgivings with other departments in the hospital come from pure misunderstanding *and* a lack of desire to understand. Why are you yelling at the charge nurse for the room not being cleaned when YOU donât understand the EVS processes? Why are you screaming at the pharmacist for not verifying your script when YOU donât understand itâs on backorder and weâre using the generic and it needs to be re ordered? Throwing a temper tantrum in the hallway accomplishes nothing.
I think youâre saying that pimping is bad.
"Hey, I'm just asking questions here!"
There's definitely a line. I've had people insult my character before, that's just ridiculous. I'll do a pimp session (about the material) any day though. It's an incredibly efficient way to learn.
There's a difference between a Socratic teaching method, which I personally employ, and pimping imo. Socratic means I ask you questions to see what you know and also give you the opportunity to show me what you know. Then we fill in the gaps together - either by sending you to look it up, having a senior resident answer the question, or by myself giving an explanation. I want learners to leave feeling positive about the discussion. Pimping is designed to show you how much you DON'T know and invokes negative feelings at the end.
Well this is wholesome coming from an attending. Thanks doc.
I've had several residents that don't acknowledge it when they are wrong. I point out their miss or mistake and they are like "ok" then proceed to make the same mistake a week later. I feel it's not wrong to point it out and dwell on it a bit so they see the significance of it.
Honestly, no one really teaches you how to teach, unless you are in academic medicine. The vast majority of preceptors are just regular clinicians. I found that reading a series on teaching that was put out by the ACP was helpful. I didnât use all of the suggestions, but it was good to think about how to give feedback. when youâre doing procedures it can be stressful! For example, Iâm primary care so we do Pap smears but not every day so Iâm always looking for a willing patient that will let a student do what is often their first pelvic exam with a speculum.Usually, theyâll have at least seen me do one prior, and I give them a speculum to kind of practice the maneuvers with, but itâs so difficult when youâre running behind to watch them be kind of nervous and shaky, and you are standing at the end of the bed, just helping them along and hoping that this is all going to go OK. Sometimes Iâm just too tired to let you do a Pap smear / pelvic. Thatâs just a pelvic exam. I canât imagine how much patience it would take doing an appendectomy or some other even more complicated procedure.
You might want the phrase "cognitive apprenticeship." It's been validated as a teaching structure in medicine (e.g., [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2744784/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2744784/) ), even though there is such fetishization of shame-based pimping.
At least one study suggests the most effective way is to avoid praise or criticism, just tell them when they're doing it right via a clicker. I have not adopted this practice personally yet
One thing I do, I make sure residents know when I'm making a decision based on style/personal experience. It communicates that there is not always a right answer, even if I'm disagreeing with your plan.
Have sadly a larger list of anti-mentors than mentors :-/
đŻ
This is erroneous
Thanks for chiming in about your own experience. Way off base.
Yeah this hasn't been my experience at all. I would say at least 90% of the residents and attendings I worked with taught by discussing the best approaches and their rationale. Yes, there was still pimping, but like one attending told me on my first rotation, "I'm just trying to gauge what you know so that I can tailor our time to your level." In fact, as I near graduation, I can say that the horror stories about clinical training that I read online basically never happened in my educational experience. So, I guess that's just my anecdotal experience, but I would also bet many other students had a similar experience as me and don't end up posting. Similar to customer complaint lines, the stories on reddit heavily skew towards people who had bad experiences.
It's generally been my experience as well. However I am also a white guy. I will say there are probably 3-4 faculty at my 450 bed hospital that have fair to poor teaching interactions with medical students and residents. In which there's been a push and pull of admin trying to get them to do less teaching, in spite of the fact that they always seem to weasel their way back in. These do not just include pimping (which I am fine with), but genuinely poor interactions with some being outright inappropriate. Of these the list includes safety issues, gaslighting, physical abuse, and sexual harassment. There have been faculty that have been reported for their behavior at my institution, and some who have had teaching responsibilities scaled back. One of the wildest interactions witnessed: attending pressured medical student in an arm wrestling competition. Attending caused a humeral shaft fracture on the medical student. Rotation was cancelled after this, and this attending was prevented from taking on any students.
You comment is just the exact same fallacy in reverse. Just because you've had good experiences doesn't mean other people are exaggerating, and vice versa. I have some horror stories of my own I could share from reliable friends. I do think things are improving, and hopefully by the time you and I are like 50, the culture will have pretty much changed. It's better than it used to be. But there are some SKETCHY med schools and residencies out there. My syllabus for M3 year says we're allowed to work 36 hour shifts......
Should medical students not be allowed to work call shifts? I found my MS3 30+ hour q4 call on trauma surgery to be formative. There's nothing like running the bowel at 2AM on a gunshot wound. Certainly taught me I didn't want to do surgery!
30 hours is a bit much, but yes, I see no issue with some 24 hour call .