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MEdIC Series: The Case of the Lazy Learners

2017-04-19T06:16:30+00:00

professionalism lazy learnerWelcome to season 4, episode 6 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 an emergency attending who questions the work-ethic, dedication and professionalism of his residents after an on-shift teaching interaction.

MEdIC: The Case of the Lazy Learners

By Dr. Andy Grock

“And that is best available evidence around tetracaine in corneal abrasions. Hopefully that answered your question!” Chris finished his mid-shift teaching with a flourish. He felt confident that his short talk had been well received and educational to the residents working with him in the emergency department that day. Always the enthusiastic teacher he added, “Before going back to work, do you have any questions about this topic or anything else you’ve been curious about?”

After a few seconds of silence, one senior resident yawned and responded, “Quick, someone ask him something so we won’t have to go back to seeing patients.” After some chuckles from the other residents, a junior resident added, “We only have 3 hours left! Let’s try to stretch this out until our shifts are over! Nothing too exciting has happened today anyways.” The residents laughed again, did not ask any further questions, and then returned to providing patient care.

Chris returned his focus to the busy emergency department and immediately noticed that numerous patients had yet to be seen with even more in waiting room. Two patients had concerning vital signs and several others had potentially dangerous chief complaints. Something about the residents’ comments and reactions started to bother Chris, but it wasn’t until his busy shift had ended that he recognized the inappropriate nature of the interaction. He began to wonder what would have happened if one of the hard-working nurses or management staff had overheard those earlier comments from his residents. Or even worse, what if a patient or their relative had  been within earshot.

Chris also considered the implications these seemingly innocent and flippant comments may have on resident perspective with regards to their profession and their responsibility to their patients. During his residency, Chris’ mentors had imparted and stressed the old adages – “the sickest patient in the room is the next patient to be seen” and “more patients, more learning.” Were these residents not cognizant of the importance of their job? Seeing patients was supposed to be an honor, a noble responsibility, not something residents should try to avoid!

The more Chris reflected, the more he started to doubt the residents’ work ethic and dedication. He was genuinely concerned about their future practice when they eventually complete their training. Chris felt guilty for not immediately addressing and correcting the comments made by his residents. He had missed a valuable opportunity to coach and demonstrate professionalism to his learners.

Discussion Questions

  1. Is resident feedback necessary in this scenario? If so, describe your approach to this situation.
  2. Could resident burnout be a factor in this scenario? If so, would that change your approach to feedback? How should we address the issue of burnout in residency training?
  3. How does your institution address lapses in resident professionalism?

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 3 experts are:

  • Dr. Sandy Dong
  • Dr. Taku Taira
  • Dr. Sean Moore

On April 14,  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
  • Loice Swisher

    Could resident burnout be a factor in this case? Absolutely, without a doubt, why would one think anything else…. I love this case because it shows how easily we are caught in the same thinking of blaming the individual without looking at the system’s impact on that individual.

    If you look at the top causes of burnout it would seem that at the very least #3 is playing out- feeling like just a cog in the wheel.
    http://www.medscape.com/features/slideshow/lifestyle/2017/overview#page=4

    As with Chris, my experience is residency a quarter of a century ago focused on some of the same adages. We were proud to be the safety net for patients. However, I do think things were much different. There was not the crushing, never-ending patient volume or soul-stealing regulations that we have now. We had more time to connect with each other- especially in the middle of the night. We got to know each other as human beings.

    It is very interesting that none of the residents have names. In addition, Chris seems to focus on what others might think had they overheard. Seemingly his approach would be to ‘show and tell’ these residents how the should act. These residents need “correction”. Maybe if we beat them they will do better in hiding their humanness.

    I think a better approach is to ‘time out’ and have a mental health check. Ask people how they are doing and why they are feeling that way. Let talk and listen- truly listen. Sometimes venting and knowing one is not alone can make a huge difference in attitude. On a few occasions actual changes can occur. Just an acknowledgement that residency is hard but that it is worth it- that you (the attending) wouldn’t want to be doing anything else- is something to hold onto.

    It seems we focus so much on the content and forget to share our passion and ourselves.

    Loice

  • John Eicken

    Loice-

    Thank you for your thoughtful comments and insight. Your comment on the camaraderie you experienced during your residency training and the experience of getting to know your colleagues as human beings is great. I wonder if the absence of resident names in the case is a result of Chris lacking that human connection you describe. In your experience how have you best integrated the ‘time out and mental health check’ into your practice? Do you perform it at a particular time before, during, or after a shift?

    • Loice Swisher

      John,
      I do emergency medicine differently than many as I am a nocturnist working at a single community hospital. Since the residents work a progressive schedule I always get them on their 5th and 6th twelve hour shift. I don’t have a set time to check on residents (or colleagues or other staff) but I have been trying to make it a thing that I check on at least one person a shift. With the residents unless there is a suspect interaction I usually ask somewhere when there is a slight slowdown in the wee hours of the night.

      I think phrasing and realization of intent matter. A few months ago I asked a resident how he was doing and he replied that he was caught up on his charts and felt pretty good at managing the patients he had. I said “ok but that was a mental health check” (the first time I used those words). He replied, “My dad was just diagnosed with metastatic prostate cancer this week.” I was shocked the answers were so different- and it brought us much closer together.

      I think Chris would find much more out by asking “Do you find joy in your work?” It doesn’t seem like these residents do. Then one can start finding out why not. Residency is the time of professional development. If one truly looked at the system, I wonder where/who they learned this from. What feeling are the other attending colleagues passing down to these residents.

      Interested in your thoughts.

      Loice

  • Alkarim Velji

    We touched on this idea of a residency as a marathon a few weeks ago. These residents have clearly developed a sense of camaraderie and are making off-hand comments during their little academic break from their marathon experience of residency. Yes, residency is a job. But there are times when the people I socialize most with are my fellow residents. Especially on a rotation where I’m putting in 75+ hours a week, the people I’m closest to are the people who are in the trenches with me. It is not a 9-5 job where you can check out and go home at the end of the day.

    In this case, the residents all go back to work. No comment is made on their work ethic on shift. If there is a specific comment about a specific resident not working hard enough when on shift, that obviously needs to be addressed. If the resident culture is shifting to one that discourages a positive work ethic, then sure, address that. But, I feel it’s a bit extreme to doubt the residents’ dedication just because off-hand comments were made during the safe space of an academic session full of other residents. Enforcing a strict culture of “all you must do is work, and only work” would drain the life out of these residents faster than what is already happening.

    The bigger question is why are the residents making these comments. I agree with Loice that an element of burnout likely exists. I remember being a clerk and having an attending tell me almost every day how much of a privilege and honor our work was. I’m reminded of his message particularly in when I am on Emergency Medicine rotations. Now about twenty months into residency, I still find it hard to wrap my head around what a privilege the job is. Patients come to see us thinking something awful is going to happen and we are their first point physician point of contact. Family members meet us for the first time as we tell them life altering news. We provide reassurance that things are okay and we tell people some of the worst news of their life. What a crazy honor we’re granted to be a figure in peoples’ lives during these life events. The question is why are residents losing site of this privilege and what culture changes need to take place? This is obviously institution and resident specific; be it coaching sessions, counselors, social events where the residents can unwind, etc.

  • Natasha Bosma Wheaton

    I agree there are two different questions here. The first has to do with the residents’ work ethic. If this is a problem outside of the comments heard, i.e. in number of patients seen, cherrypicking patients etc, this needs to be addressed with true “feedback”. However, if the overall work ethic is good then we are left with these comments which I agree, are suggestive of potential burnout. Catching these residents during a slow time on shift, or sending an email to their faculty mentor or a member of educational leadership to check in with them, may be helpful. I have found that often when residents start making comments like this it is because they are feeling increasing symptoms of burnout, specifically depersonalization. You see this in the “nothing cool has happened today anyway” comment. Getting to the bottom off why they are feeling this way, rather than just asking the residents to not share how they are feeling, has been a better approach in my experience. Further, I have noticed a pattern to burnout symptoms (or at least comments like these) in residency with second year (or third in four year programs) with the highest rates. Because of this, I am more concerned if this comment comes from a PGY1 (especially early on) or a PGY3 about to graduate. In that case, I will often pull them in personally to my office to chat about how things are going and to potentially take a MBI also.

    • John Bailitz

      Is resident feedback necessary in this scenario? If so, describe your approach to this situation.

      Instead of “feedback”, start with Empathy. The “teacher” has no understanding of why the comments were made. Rather than pushing mini-lectures at students who also caught the episode of EMRap on this topic, consider making the effort to connect at the start of every shift by asking the student “how is life?”. Then get to the bedside and make the shift interesting by asking the student “what if” questions. For example, “what if this patient has a deep corneal abrasion, but refused opiates due to prior issues with addiction – what else might we consider?”. Every case can be interesting with a bit of imagination. Then teach one pearl, save the sermon.

      Could resident burnout be a factor in this scenario? If so, would that change your approach to feedback? How should we address the issue of burnout in residency training?

      Burnout/Wellness/Resiliency i.e. our own health, must always be an important issue. Stop blaming the burnout victim. Instead address the system that has taken away much of the joy of medicine. Bring the discussion into the open. Address ways to make the EMR work for you and how paying attention to the patient’s experience actually improves your experience of the shift too.

      How does your institution address lapses in resident professionalism?

      Be an example of professionalism first. One mentor defined this as “Always aspiring to altruism, accountability, duty, honor, honesty, integrity, respect for all others, empathy and excellence in all endeavors (ADHIRE). Then determine if this is really a lapse in your trainees professionalism, or your institution’s professionalism for failing to care for their employees. When individual professionalism issues really exist, start with questions again, “explain what happened?”, “why” x 5, “how may we best move forward for you and a program?”.