MEdIC Series: The Case of Shifting Expectations

2017-03-01T10:38:25+00:00

overconfident poseWelcome to season 4, episode 5 of the ALiEM Medical Education in Cases (MEdIC) series! Our team (Drs. Tamara McColl, Teresa Chan, John Eicken, Sarah Luckett-Gatopoulos, Eve Purdy, Alkarim Velji and Brent Thoma) is pleased to welcome you to our online community of practice where we discuss the practice of academic medicine!

This month, we present a case of a new emergency attending who feels like she has lost control of her department while working with an overconfident senior resident.

MEdIC: The Case of Shifting Expectations

By Dr. Teresa Chan

Deborah had started as a new attending at St. Elsewhere Hospital and had initially found it difficult to transition to the new environment. The computer system was different from the one she had trained on, the layout of the department was new, it was busier with more patients and more consultants and although the people seemed nice, they were strangers. After three weeks, however, she was finally starting to hit her stride.

Deb was finding her shift especially difficult today.

Deb had been assigned a senior resident for the first time. Supervising Donald was turning out to be a lot more difficult than she had expected.

During her training, Deb had been interested in learning to teach on shift. She had even set up teaching shifts in her final year of residency, hoping to perfect her skills. But in all of her shifts, she had only ever supervised junior residents at least two years behind her in training.

Donald was a confident senior resident, to put it mildly. At her faculty orientation, Deb had been given a primer on all the residents in the program, and she recalled the program director’s description of him, “Donald is… confident. He sometimes borders on cocky, but he’s performed well on the shelf exams and he does a lot of moonlighting, so he has racked up a lot of experience.”

Deb had felt undermined throughout her whole shift. The nurses had looked to Donald for instruction, and had even overridden some of her orders based on his suggestions during a cardiac arrest case. Fortunately, everything had turned out well for the patient, and he was now safely in the intensive care unit (ICU). Still, Deb had noticed that Donald had discharged home a few patients without even telling her, and had forgotten to order a second set of cardiac enzymes in one of his low risk chest pain patients. Deb had asked Donald to call the patient back; luck would have it that he was still in his car in the parking garage and happily obliged.

It was now nearly a half-hour to the end of their shift together, and Deb was feeling very uneasy about how things were going. She had asked Donald a few times to “run the board” with her and update her about his patient-care decisions. Inevitably, they had been interrupted every time they tried to complete this exercise and Deb was feeling like she had lost all control of the department. It was challenging to second the bulk of the patient care to someone else. Adding to that challenge, Donald was intent on making sure that he was “running a tight ship” and insisted that Deb just “sit back and relax” like the other attendings usually do.

“Oh, hey Debbie! How are things?” asked Josephine as she strolled into the department, coffee in hand. Josephine was Deb’s relief, and at this point she was a sight for sore eyes. Josephine also happened to be Deb’s assigned faculty mentor, and they had met a few times recently to discuss how she was settling in to the new department.

Deb looked quickly around the room to make sure she and Josephine were alone.

“Um, it’s been a rough shift,” she whispered.

“Oh?” inquired Josephine with her eyebrows raised. “How so?”

“Well, to be honest, I’m not used to working with senior residents, and I feel like I’ve sort of lost control of the department,” she admitted sheepishly.

Josephine nodded sagely, taking a sip of her coffee. She remembered how she had felt when she had first started. As a new attending, it had been hard enough to finally start thinking independently, but supervising senior residents added a whole other layer of complexity.

Josephine pondered. What advice could she give Deborah to help her in her current situation?

Discussion Questions

For Residents:

  1. How does working with junior faculty members differ from working with senior faculty members?
  2. Can you identify things that junior faculty members have done well when supervising you?
  3. How do you provide feedback to someone who is senior to you? (i.e. How do you tell a faculty member that you appreciated something that they did when they were supervising you? How do you tell a faculty member when they did something that made you uncomfortable?)

For Junior Clinician Educators:

  1. Have you had any difficult situations while teaching senior residents? If so, what have been some problems have you encountered?
  2. What advice have you received from senior educators about handling senior residents?

For Senior Educators:

  1. If you were Josephine, what advice would you give Deborah?
  2. Are there any unique approaches that you use with senior residents that are different ones you use when you teach junior ones?
  3. What are some systems that you use to mitigate transitional problems like the ones highlighted in this case?

 


Weekly Wrap Up

As always, we will post the expert responses and a curated commentary derived from the community responses 2 weeks after the case is published.

This month, our 2 experts are:

  • Dr. Warren Cheung
  • Dr. Kimo Takayesu

On March 10,  2017 we will post the curated commentary and expert responses to this case! After that date, you may continue to comment below, but your commentary will no longer be integrated into the curated commentary. That said, we’d love to hear from you, so please comment below!

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

MEdIC Series: The Concept

Tamara McColl, MD FRCPC MEd(c)

Tamara McColl, MD FRCPC MEd(c)

Associate Editor, ALiEM MEdIC Series
Emergency Physician, St. Boniface Hospital, WRHA
Academic Lead, Educational Scholarship
Department of Emergency Medicine
University of Manitoba
  • Kicking off this conversation… I will fully admit that I have yet to really have this situation as a staff person, but I recall being that over-confident resident more than once. The faculty members who mentored me totally handled it with aplomb, but I don’t know their secrets to success… so hoping others can provide insight!

  • S Luckett G

    One of the hardest things to do as a resident is work with a new attending. The attending doesn’t know you well enough to know your skill set, and may not trust you. I know some attendings will balk, but as a resident you may not trust your staff person, either, if you’ve never worked with them before. It’s a two-way street.

    The best interactions I’ve had with staff who were new (or just new to me) were ones where we set expectations prior to the shift. Some attendings will broach the topic, but many won’t, and in those situations it behooves us as residents to ask: ‘What are you comfortable with me doing today?’ or ‘Usually I will work up patients on my own and I’ll come to you if I need help or am ready to disposition a few patients. Will that be okay today?’

    Senior faculty often offer a lot of leeway, whereas the newest staff tend to be more involved with patient care and disposition; it’s understandable, and it helps if the attending establishes that expectation early on. It’s easy to feel trampled as a resident, especially when you are becoming more senior and gaining comfort with your own autonomy. Sometimes attendings who follow too closely project an air of distrust, infantilisation, or wariness that can come across as a grating, micromanagerial style or give the impression that they do not think you are knowledgable enough to make decisions.

    As for providing feedback to faculty, I’ve found it’s nearly always impossible to do fruitfully. No matter how enlightened or eager for feedback a faculty person claims to be, or how tactful and respectful you try to be, most faculty do not welcome feedback from learners. My experience has been that most try to explain why they behaved in a certain way (i.e., why you, as the feedback giver, are wrong), use it as an opportunity to criticise your performance as a resident (thereby negating the worth of your feedback), or dismiss it (usually in a tight-lipped way that betrays their misgiving at ever entering the interaction with you). In truth, that’s how most people in general react to feedback, so you can’t really blame them, can you?

    Admittedly, I have a bit of a blunt style, and that may be part of what has led to these reactions, but my experience has been that it is better to keep my mouth shut than to even attempt to explain to a faculty member that something they have done has made me feel uncomfortable. Instead, I try to focus on the positive (‘Thanks so much for that teaching on nec fasc. I hadn’t thought of some of the points that you brought up’; ‘I really appreciate that you came with me for several rounds of discharge instructions. It made me feel self-conscious but now I think I have come to a better understanding of what I should be doing’; ‘Thanks for letting me do that intubation my own way. I appreciated that you trusted me to try something different’.). I reserve my real feelings and feedback for faculty with whom I have an established relationship.

    • Robert R Cooney

      You bring up an interesting point about “trust.” You’re absolutely correct in that it’s a 2 way street. Something additional to consider though. I was recently reading David Marquet’s “Turn This Ship Around” when he delved deeply into the need to separate “trust” from “ability/competence.” The simple example is that someone is driving you somewhere. They turn left when you thought they should turn right. Do you trust them? If you think that they’re trying to get you where you need to go, then of course you trust them. As he goes on to tease apart, just because you trust them to get you there, doesn’t mean that they can do it; this is ability/competence. Ability, of course, is composed of knowledge, skills, and technical competence. As leaders and educators this distinction is critical. Trust connotes an emotion and often brings with it emotional baggage that interferes with the conversations we need to have about ability. So the next time you feel that you’re being micromanaged, maybe ask directly whether they trust you. If they say yes, then ask if they believe you have the ability to do what you are intending to do. If again they say yes, then it sets up the feedback conversation about how their supervisory style makes you feel vulnerable, infantilized etc. I do recommend approaching it as a question though. “If you trust me and believe that I have the ability, why are you following me into every room; questioning every decision, etc?” I would guess that many are looking to “coach” just doing it through a style to doesn’t align with your preferred style. It’s when they say “no” that you can get some valuable feedback for improvement.

  • Victoria Brazil

    Hey thanks for the great case.
    Based on my age, I probably fall into your ‘senior educator’ category (yeah, I know I look younger…….:-) )

    And i agree with previous comments – this is kind of easier for me because now i realise that in many respects – the senior trainee is often more up to date with clinical literature, probably works full time ( and hence sees the nurses more than i do as only part time clinical ), and has more recent procedural experience.
    So i think my ‘value add’ in the department is different to what it was 15 years ago as new ED consultant (attending), and i don’t find that as ‘threatening’ to my sense of being in charge as i used to.
    The change for me was shifting from “here’s what i would do and he needs to do that” (kind of where Deb is i think) to “what he’s doing is OK so i can live with it” , even if I’d do it differently

    However you imply Donald is overconfident, which is tougher ie “what he’s doing is not quite OK, and worse, he thinks it is”
    If i thought he was less sensitive to feedback – I might just make some calls and change management plan, using position power i guess, although explaining why. I’l be honest – sometimes these trainees need to be fairly bluntly called out (that IS one of my ‘value adds’)
    If i thought more receptive, then I’d pick my cases to go into some depth with the questioning – not ‘run the whole board’ but rather pick 2 or 3 where the decisions look dodgy.
    And then based on response to those things – i might have an open chat about the issue thats arisen for me.

    To be honest i suspect that Donald is just trying to work really hard and ‘step up’ himself, but perhaps doesn’t quite appreciate the impact that has on Deb, and might be oblivious to her perceptions of a mild power struggle

    There might be some gender issues as well, and occasionally they have a cultural dimension too. No specific indication of that here, but i have experienced that.

    However i think you are really looking for the advice to give Deb.
    I would think of it like a coaching conversation
    ie no point in saying ‘lighten up’, or ‘don’t be so anal’ or even over empathizing ‘yeah, typical male ED cowboy’
    Transitions are called transitions for a reason. Its a process, and it takes time and a few bumps in the road. I think holding up a mirror for Deb and helping her thinking about pros and cons of her responses/ approaches is all I can do. And normalise it.
    …. And maybe ask her to put the IV cannula in the neonate for me because I know she’ll be heaps better at it than me 🙂

    vb

  • Victoria Brazil

    Hey thanks for the great case.
    Based on my age, I probably fall into your ‘senior educator’ category (yeah, I know I look younger…….:-) )
    And i agree with previous comments – this is kind of easier for me because now i realise that in many respects – the senior trainee is often more up to date with clinical literature, probably works full time ( and hence sees the nurses more than i do as only part time clinical ), and has more recent procedural experience.
    So i think my ‘value add’ in the department is different to what it was 15 years ago as new ED consultant (attending), and i don’t find that as ‘threatening’ to my sense of being in charge as i used to.
    The change for me was shifting from “here’s what i would do and he needs to do that” (kind of where Deb is i think) to “what he’s doing is OK so i can live with it” , even if I’d do it differently
    However you imply Donald is overconfident, which is tougher ie “what he’s doing is not quite OK, and worse, he thinks it is”
    If i thought he was less sensitive to feedback – I might just make some calls and change management plan, using position power i guess, although explaining why. I’l be honest – sometimes these trainees need to be fairly bluntly called out (that IS one of my ‘value adds’)
    If i thought more receptive, then I’d pick my cases to go into some depth with the questioning – not ‘run the whole board’ but rather pick 2 or 3 where the decisions look dodgy.
    And then based on response to those things – i might have an open chat about the issue thats arisen for me.
    To be honest i suspect that Donald is just trying to work really hard and ‘step up’ himself, but perhaps doesn’t quite appreciate the impact that has on Deb, and might be oblivious to her perceptions of a mild power struggle
    There might be some gender issues as well, and occasionally they have a cultural dimension too. No specific indication of that here, but i have experienced that.
    However i think you are really looking for the advice to give Deb.
    I would think of it like a coaching conversation
    ie no point in saying ‘lighten up’, or ‘don’t be so anal’ or even over empathizing ‘yeah, typical male ED cowboy’
    Transitions are called transitions for a reason. Its a process, and it takes time and a few bumps in the road. I think holding up a mirror for Deb and helping her thinking about pros and cons of her responses/ approaches is all I can do. And normalise it.
    …. And maybe ask her to put the IV cannula in the neonate for me because I know she’ll be heaps better at it than me 🙂
    vb

    • Tamara McColl

      Thanks for commenting, Victoria! Great insights!

  • Ben Symon

    I agree, great case! And as a junior educator and new consultant very easy to relate to.

    Maybe a clumsy analogy but I think there are parallels between raising teenagers and teaching junior medical staff… You need to harness their passion and foster independent, critical thought, but to do so involves an element of risk. Unlike in teenagers the risk is not just personal, but might lead to patient harm if allowed to run unchecked.

    A bit of over confidence is an important developmental step in reaching an independent, expert level of practice. And trainees don’t thrive in a ‘helicopter parent’ style environment. As such I agree w Vic that the power of a good attending is to provide that stable hand with more clinical experience to slow the learner down and say “hold on, have you thought about…. Etc”.

    For me as a junior educator the challenges in finding that balance between fostering independent practitioners and maintaining patient safety are :

    1. As a new consultant at times insecure about my knowledge, it is easy to register an over confident trainee as a personal threat, and incorrectly clamp down w negativity or over criticism.

    2. The genuinely unconsciously incompetent trainee who sounds convincing and self assured is easy to miss unless you work w them frequently. The halo effect is powerful and confidence in presentation style can = assumption that clinical assessment is good.

    3. In Paeds emergency, the natural history for most presenting patients’ pathology is to self resolve. This leads to an experiential bias for junior trainees who have not seen enough cases to see the bad outcomes for those rare patients who have serious illness. Making them aware of the importance of considering low pre test probability diagnoses can be in direct conflict w their experience that ‘all their patients turn out fine’, and you can come out as over bearing and paranoid.

    4. Attendings/consultants get very used to parallel play. They often don’t work directly together w other specialists in the same field, and they’re used to getting their way on the floor. Learning to step back and allow trainees ‘the dignity of risk’ is an immense personal challenge, particularly as we are the ones who hold the actual medico legal risk. But like a parent prepared to let their child make mistakes and experience failure, a safe level of trainee independence will likely be rewarded w thriving candidates.

    Easier said than done! At least for me.

    • Agreed with checking your own feelings and that feeling of feeling “personally threatened”….

      We did a local case discussion at our site to pilot this case before I submitted it, and we had a really good discussion about how attendings can (and should) check their reactions and manage their reactions. Much like we get taught when we do our psychiatry rotations, there can be strong emotions when dealing with learners, but we need to make sure we keep our own perceptions and emotions in check and engage in reflexive activities and be aware of our own reactions (and. countertransference!).

      • Ben Symon

        Yes I think understanding transferrance, emotional contagion and awareness of our own primitive defence mechanisms is under taught in e.r.

  • Tracy Rahall

    I enjoyed the case. I think this is a situation I have encountered frequently at different stages of training. As the “senior attending” – that makes me sound old…I have had this play out both as the senior resident myself reporting to a new attending and in a variety of hats as the attending supervising medics, PAs, NPs, junior and senior residents, and now as a Fellowship Director supervising Fellows in the emergency department. I think, regardless of what level of training the individual I am supervising is at, the key factor in response to that individual has a lot to do with how well I think they will respond to coaching and to critique. The key issue for me is whether the patient care is OK – I am less invested in whether they do it “my way” as long as they can provide a good evidence-based approach to how they are managing or working up their patients. In working with new individuals I am upfront at the beginning of my first shift with them what my expectations are and how I work. I expect them to be able to initiate a diagnostic plan and treatment for the patient on their own but I expect them to “run me through” their thinking and how they arrived at their DDx. I am happy to facilitate their running on the department while making it clear this is still my department and my responsibility. My goal is not to be the armchair quarterback but to help fine tune how the residents or Fellows, in my case, “run their game” and like any good coach I have to know what they are doing in order to do that. I don’t micromanage but I review the tests and “eyeball” concerning patients because I can tell more about a patient in 30 seconds at bedside than in 5-10 minutes of patient presentation. That being said it is important to gauge my critique based on whether this resident is just eager to assert his autonomy, is insecure and masking that with cockiness, or just being a “wanker”. I can have patience with all but the “wanker” who just needs an attitude adjustment. For me it’s a matter of just paying attention to emotional cues and controlling my response to them. I have less ego issues than when I was younger – now being 18 years post-residency which helps.

    • Hi Tracy:
      Thanks for sharing. Why do you think that your ego has changed over time? What part of the last 18 years has shaped that?
      #JustCurious

      • Tracy Rahall

        Teresa,
        I think part of it is experience – the sense of “I got the hat, got the T-shirt” in that I have already been tested in the fire so to speak and have proven I can run an acute medical or trauma resuscitation and can an extremely busy department. I have taught EM residents went back to clinical medicine and then went back to a semi-academic position to keep things fresh. I think partly as a result of these accomplishments and probably as a result of a progressive change in my ego-mind and ego-drivenness as I have gotten older I don’t have the need to “prove myself” to anyone or anything. I don’t have the need to seek anyone’s approval. I know who I am as an individual and as a clinician. I have always felt and tell my younger partners if they ask that it takes about 7 years to feel comfortable as a physician in EM – partly because EM learning is based a great deal of what you see and it takes that long to “see enough”. I have been through that proving ground. Part of it may also be my stage in life as a woman – I know who I am and what I stand for. I have made my mistakes (probably more than my fair share) and have learned from my failures. I embrace my “flaws” and am more accepting of those in others. I am comfortable in my skin and that helps me to better relax when working with others as long as I know they are f#@^ing things up. I am far from perfect and although I run a tight ship I am OK if someone wants to try their hand at steering the ship – just watch out for rocks…

  • Tamara McColl

    Great discussion thus far! We’ve also had a lot of buzz on twitter so I’d like to share some of our twitter comments on how various EM educators approach overconfident learners!

    @hrosenberg33 (Dr. Hans Rosenberg)
    Acknowledge confidence – explain fine line b/n confidence & arrogance (1)
    I explain: “You might not realize, but colleagues could see you as overconfident” (2)
    Finally let them know how to improve: respect experience and knowledge of others (3)

    @KariSampsel (Dr. Kari Sampsel)
    Totally agree. And ask a deeper question to ensure understands

    @ThurgurTox (Dr. Lisa Thurgur)
    Make it a teachable moment on teaching overconfident learner. Flip the tables – ask the senior what he/she’d do in situation

    @lisadfischer (Dr. Lisa Fischer)
    I say “it’s a strength and not a weakness to ask for help”

    @Stella_Yiu (Dr. Stella Yiu)
    Tricky case.
    1. I make it about me not them. ‘My rule is that i always see patients/look at ecg/imaging regardless of level of training.’
    2. Share personal cases about being humbled
    3. Explain cognitive biases/blindspots by being overconfident.

    @DanWarrenMD (Dr. Daniel Warren)
    Hold a mirror to their ‪#competence
    Mismatch of competence and confidence is the most dangerous condition in ‪#MedEd AND in practice. Humility is underrated, hard to teach.

    @EM_Educator (Dr. Rob Rogers)
    I like to give them scenarios that push them beyond their overconfidence

  • Robert R Cooney

    So, I guess I’m slowly heading into “senior” territory. As program leadership, I see several concerning things with this case. ALL of these stem from a lack of communication. As I look through the case, a few things that Don did jump out:

    Overriding orders
    Discharging patients without a discussion
    Ignoring a faculty member’s direct request to “run the board.”

    If we phrase this in the language of the milestones, Don is violating the principles of the Team Management milestone (ICS2) and the level 2 subcompetency: “Communicates pertinent information to emergency physicians and other healthcare colleagues.”

    This competency exists because it is essential that teams communicate. This is even more critical when a new member joins the team. They don’t know who has the ability to do anything. To me, Don’s insistence on “running a tight ship” instead of communicating (and downplaying concerns, “just sit back and relax) only shows me that he doesn’t yet demonstrate that he can be trusted and his behaviors only support the case against him. He is performing “below” the expected level. He might have been completely competent in his patient management, testing, etc, BUT he failed to communicate. Also, it wasn’t that he did just one of the above, he did ALL of them on a singular shift. As a faculty member, I will extend a longer and longer leash as long as I know what a resident plans to do and why they’re doing it that way. Sometimes, the best discussions come from our disagreements over testing, treatment, etc.

    If I were giving advice to Deborah, I would help her explore her feelings a little more. If it turns out that she is concerned about the above, then I think it is worth coaching her to have a “crucial conversation” with Don. We could practice a few times with me playing the role of Don. This would allow her to approach him with her concerns and will set the expectations for their future work together.

  • Loice Swisher

    Since I am fast approaching a quarter of a century since graduation from residency (which I then became an attending at), must be I qualify for the last set of questions.

    “Welcome to the club. Supervising senior residents was one of the hardest things I had to get used to when I first started. Let’s find some time soon to chat and share stories. It gets easier.”

    That is where I would start- you are not alone, I understand, it gets better. This is tough to talk about because when one feels “like they lost control” then it feels like a failure and that talking to someone else that you will be judged and that you might be blamed and shamed for it. Recently I have looked at Brene Brown’s Shame Resilience Theory- shame withers when spoken to an empathetic listener. It can be shocking when one just listens how the other person comes to new places all on their own.

    I think most of us have this- the feeling of being consciously incompetent with the big jump to carrying the weight of “the final answer”. It is good to talk with others to find their tricks in what makes them feel in control of the chaos we call our emergency department. One thing I do is open the EMRs- look at the chief complaint, the vitals, the PMH and the meds- usually I will have a pretty good idea of my questions if not the likely path. If I’m unsure I’ll ask the nurse for their thoughts. Then if the resident presents that path that I think we are going to go I usually am easy on going that way. The discrepancies are the ones that focus on.

    At our places the docs do discharges. Sometimes I will do the discharge for a patient that the resident has taken significant control of the case. This will give me more time to talk with the patient and a final right to veto.

    Perhaps the best thing to know is the expectations you have that will let you sleep at night then assuming it is within reasonable practice make it clear at the beginning of a time working together unapologetically.

  • Felix Ankel

    Transitions tend to be tricky. A couple of resources that I have found helpful and suggest to faculty in transition are the following.
    1. https://www.amazon.com/First-90-Days-Strategies-Expanded/dp/1422188612 We tend to have a bias towards action in new jobs. One suggestions is to observe observe observe until it hurts, then start with action
    2. https://www.amazon.com/Charisma-Myth-Science-Personal-Magnetism/dp/1591845947 although I have ambivalence about the value of “charisma” in the traditional sense, this book discusses the importance of presence, warmth, and power (I prefer the term strength) and discusses techniques to achieve them. As faculty we tend to to try to add value “teach” with each patient encounter https://icenetblog.royalcollege.ca/2015/06/05/key-skills-for-meded-leaders-separation-multiply-more-micromanage-less/
    When faculty feel that things do not seem to “click” in their teams I ask them
    1. Are you trying to add value to every conversation or do you let others maximize their contribution?
    2. Are you making a point or making a difference?
    A3. re you maximizing a position or elevating a conversation?

    This is more on the faculty reflective side. Some of the resident behaviors need specific feedback well described by others in this thread