by Alison Hayward, MD
Nearly every medical student, at some point during training, will have a negative encounter with someone higher up on the ladder. One of the most difficult aspects of medical school is the vulnerability of medical students to criticism or disciplinary action due to these types of encounters. These situations can lead to the most dreaded of outcomes – a negative comment in your dean’s letter or file.
Your skills in interacting with others will be put to the test not only with patients, but also with physicians and support staff. Oftentimes, a perceived offense to the ancillary personnel can be particularly damning, because physicians often have close relationships with these staff members.
This can also work in your favor: getting in the good graces of the rest of the staff can help secure a favorable impression on your supervisors. Remember, some attendings may be quite removed from your daily activities as a medical student. If this is the case, they may count on secondhand reports from other staff members as part of your evaluation.
With seemingly innumerable potential pitfalls, the third year clerkships in particular can be maddening. At no time are you lower on the totem pole, and sometimes it can feel like other staff members – particularly those normally at the bottom of the pecking order – revel in making you feel completely clumsy and irrelevant. It is a difficult situation to be in, but the key is to keep smiling. Being cheerful and enthusiastic, as many students who have excelled on the wards know, is usually more important than getting “pimping” questions correct. Many attendings believe in a variation of the adage, “knowledge can be taught, but personality is forever.”
Students can often be heard bitterly complaining about the subjective nature of clerkship evaluations. Since evaluations of one’s personality are necessarily subjective, and personal interactions will figure prominently in nearly any career, there is little chance that clerkship evaluations will cease to be an important factor in residency admissions. Being able to “play nice” will help you in any profession, regardless of your mastery of the facts or your physical ability to do procedures. Therefore, simply raging against the machine, while perhaps cathartic, is not the solution.
So what are your options, aside from being relentlessly pollyannaish and striving to get along well with everyone you meet? If you have an abrasive personality or commit a truly heinous act, then prayer may be your only resort. However, if you are like many medical students and have been misconstrued in something you said or did despite good intentions, you may have alternatives.
First, apologize regardless of the situation and whether you feel the complaints are justified. Not only will you hopefully improve relations with the individual, if your future career is more important to you than the flap in question, you may avoid repercussions. Attempts to defend yourself may add fuel to the fire, because you will appear to be questioning authority.
Titrate your apology to the offense: if it is minor, a simple apology will suffice, but if it is serious, a more extensive explanation may be required. In fact, the best response to a low-level negative comment (such as the type you may receive daily from a grouchy, sleep-deprived resident or attending) is usually just a cheery “all right, I see what you are saying, I will try not to let it happen again!” Although this type of response may not only feel false but may be tough to fake, mastering it will help you deal with a multitude of situations that have the potential to go on a downwards spiral. It is also often said that the best doctors are great actors.
Second, if another authority is available who you feel will be sympathetic, go to them for help. For example, if your problem is with your preceptor, but you have a kind clerkship director, make your case to that person. If you go down this road, never appear to be accusing the person who criticized you. Explain it in terms of being a misunderstanding, or propose extra credit work you could do to remedy your grade. If you come off well in this encounter, this person may leave out the offending comments or alter your grade accordingly. If this option is not feasible, or if the person you appeal to is unwilling to change their colleague’s ruling, consider giving up. Further pushing may get you into more trouble.
Finally, as a last resort, find out if your institution has an “ombudsman” or “ombudsperson”. These individuals act as student advocates in situations where students have been intimidated, harassed or otherwise wronged by faculty members. Ombudspeople are meant to serve as equalizers in the large power differential between students and attendings.
If none of the above is helpful or appropriate, consider writing a letter that you will not send stating your grievances. You will likely feel better after making your case on paper/in e-mail, but you will not risk getting yourself in deeper by appearing to accuse, blame, or inflame those who are above you.
Above all, the rule in clerkships is to try to avoid the negative encounter in the first place. Remember that you are being watched. The way you talk, the way you dress, and the way you treat patients are being minutely scrutinized. Remember that one of the most common accusations leveled against medical students is that they have acted “unprofessionally”. Avoid any language that even borders upon ‘colorful’, even if you are only in the company of colleagues. Do not make jokes with colleagues or patients on any political, religious, or personal topics, particularly about the patient’s appearance. Do not complain about a co-worker’s behavior to another staff member unless it is of crucial importance to do so.
It is also prudent to avoid giving negative feedback (about persons or activities on the rotation) in general, unless you can do so anonymously. You are not protected from repercussions otherwise. You have the rest of your career to be opinionated and blunt. As a student, stay conservative and positive. And, because expectations of students can be unrealistic, if you cannot avoid a reprimand, use the tips above to counter it.
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