Sunday, May 15, 2011

Standards of "I don't care."

2011 graduates Zwade M. and Andrew B., after matching at Harvard programs.

Zwade M. and Andrew B. are two of the most professional, respectful and altruistic young doctors I have ever met. Seriously. I met Andrew B. on his first day of medical school back in 2007, and I met Zwade M. very early in his second year of school.  I can tell you that from the moment I met both of them, they were ultra-gentlemenly, exquisitely thoughtful and unbelievably careful in every single one of their professional interactions.  Although several of us Grady doctors were involved in both of their medical educations, I am pretty sure that we can't take any credit for their excellent behaviors.

Check it. Unlike these two dudes, every now and then you encounter a learner in the hospital that makes you scratch your head and say, "Huh?"  Or better yet, makes you want to say, "You do realize I can hear you and see you, don't you?"

One of my friends and fellow Grady doctors was working with an intern recently who, for all intents and purposes, simply didn't give a damn. I mean a damn.  Now let me clarify:  This wasn't a situation where he was poking patients in the eyes or sedating folks so he could sleep. He was doing his work, and wasn't an assassin but. . . .as far as his interactions with my colleague, his supervising physician?  This dude might has well have given her the finger.

The guy showed up every day dressed like a slouch, and was totally unapologetic about it.  He walked off of her rounds, texted on his cell while she was talking, announced repeatedly that "he was just trying to get through the month," and even took the liberty to alert my friend repeatedly of the fact that he was going to be leaving at some oddly unappointed-by-her time.  It was crazy.  This was a whole new standard of "I don't care."

So this particular person was just rotating on Internal Medicine for the month, and had made it abundantly clear that doing so was a nasty little lump that he was being forced to take.  My colleague, who could quite possibly be one of the most caring, kind, empathic, thoughtful, humanistic, professional physicians I know, was really bothered by this. More than bothered. It hurt her feelings.

I'd like to think that I wouldn't have put up with this kind of behavior. I'd like to think that the reason that I haven't really been in a situation is an attestation of the handle I have on my teams. Ha. I'd like to think that. Instead, I've probably just been lucky.  

Another one of my fellow Grady doctors was dealing with a similar situation with a medical student--you know, that same perplexing don't-give-a-eff behavior that is so puzzling to the faculty member that they wonder if they've somehow become invisible.  This particular attending knew this learner well, and Lord knows had fought the good fight in trying to get the student on the straight and narrow. More than the first person, this person was also bothered. And maybe even a little bit hurt, too.

So what does all that mean?  Like, what does it mean when a learner simply tells a faculty member to "stick it" in no uncertain terms?  Does it mean that we have fallen short?  Does it mean that the person simply has no "home-training?" (As the Grady elders call it.) Is it just a sign of the times, where these young whippersnappers have just become more entitled?

Beyond Zwade M. and Andrew B., I know plenty of students and residents that are beyond professional. Jackie G., Alanna S., Francois R., Roger A., Roy A.. . . .the list goes on and on. Now that I think of it, there is this one second year student that I know quite well who is, in particular, professionalism personified.  She is an eager learner. She values medical education so much that the excitement oozes from every part of her being.  Her coat couldn't be whiter. Her posture couldn't be straighter. And as far as being bright-eyed and bushy-tailed? Fuggeddaboudit. This student has taken that to a whole 'nother level--and not in that brown nosey way, either. And you know what? This student was like that from the start.

That leaves me with the point of this random rambling:

Can we teach professionalism?

Here's the deal--as medical educators we are expected to help guide our learners toward professional behaviors. Yeah, yeah. . . .we serve as role models and such, but seriously, we are actually mandated to teach and evaluate the students and residents on their professionalism. They are supposed to be competent in the area of "professionalism" before they graduate, which gets hard, especially when they aren't, well, professional.

The Zwades and the Andrews of the world are easy. They show up in their white coats with their deferential behaviors, their pleases and their thank you's. They take notes while you teach and listen intently during rounds. They show up on time and pitch in to help others.  And with the flick of your wrist, you sing their professional praises on evaluations, feeling like you somehow can take a little credit for it knowing deep down that most of that has to do with what the Grady elders call "mama 'nem."

So what's a medical educator to do?  What do you do when someone just doesn't give a damn?

I am really asking because I am interested in your thoughts. I really want to know how folks suggest we go about doing this. Not just doctors, either. But people's mamas and you non-medical folk.  See, because you guys are the ones that will be lying in hospital beds when folks like that middle-finger-giving young doctor strolls in to write life saving orders in your chart.

Do we put them in time out?  Do we shrug it off and suggest that some are lost causes?  Do we pounce on top of them with a knee in their chest and a nasty snarl saying, "Don't make me put my foot in you. . ." Uhhhh, you get what I'm saying.  Like. . . I don't know. I really don't know.

Oh yeah, and I acknowledge that we could be the problem, too. Are we not firm enough? Are we sending the wrong message to the learners through our behaviors or is it that weak leadership manifests as the egregiously unprofessional behavior in those don't-give-a-damners? Is it a respect thing? Is it a . . .gulp. . . woman thing?  Like, would these same learners tell a man to stick it?  I hate to even go there, but neither of the aforementioned faculty were male.


So that's what's on my mind this morning. What y'all got to say about all this?


  1. I've been on both sides of this fence. In an earlier job, I had a supervisor take me aside and tell me that unless I started taking things much more seriously, I would need to consider a rapid career change (thankfully, I made the necessary attitude adjustment). In subsequent jobs, I've had to take this role on myself.

    My own advice: be clear, at the beginning, about what your expectations are. If the individual isn't living up to those expectations, correct the behavior quickly but privately. In other words, don't chastise him/her in front of others (at least not for the first offense) but don't ignore it either...address it as quickly as you can do so alone with the individual (not to exceed the end of the day). Be kind, and try to identify the root of the issue (the early-departer may have a family member in an ICU himself or something) but make it clear that the behavior has been noticed, is unacceptable, and will not be permitted. Reinforce the expectations again. Repeat as necessary, but I'd say not more then twice in the space of a month. If that doesn't solve the problem, it needs to be "kicked upstairs" so to speak.

    In the end, though, some people simply won't respond to this type of counseling. In the case you describe, it's not clear if a bad evaluation from the supervising attending could have had a long-term impact. The individual may be able to escape a single bad evaluation on a single rotation, and he/she may know that, and thus won't modify behaviors. That's a system issue.

    Good luck!

  2. I really don't know the answer here but as with children who don't know it isn't OK to walk on the sofa until you tell them and snatch them off the sofa when they do....I think these don't-give-an-eff students need to be confronted with their behavior. I realize they should already know this, but perhaps they don't. As for the consequences, I don't know enough about the system to suggest any, but I bet you do! Because being a doctor is a privilege and an honor and someone needs to whomp them upside the head (figuratively) when they act like IDIOTS. Maybe this time it will make an impression.

  3. 'Can we teach professionalism?'

    I read your post before I went to school, and I've been thinking about it all day.

    In some ways, I think you can. But at the age that I'm assuming that this person is now, you've either got it or you don't.

    If I were the person involved, I would have a word with them in private to make sure that they fully understand what is expected of them. I mean, the way I talk to my teachers is completely different to the way that I talk to my friends; and the way that you talk to your patients is obviously going to be very different from the way that you talk to your family. This is because you have an understanding of the different levels of formality and professionalism required in each situation. But some people just don't get it.

    I wholeheartedly agree that professionalism should be 'taught' and graded. After all, having the grades doesn't mean that you'll make a good doctor, or a good anything, for that matter. It's about SO much more than that.

  4. Sadly, I do believe that a lot of what is "professionalism" has to be instilled in a person before they hit puberty. Can people be taught to act professionally? I think with either large enough threats of bad consequences or a strong enough lure of rewards they can be compelled to "act" professionally, but behind turned backs and closed doors, will they make this professionalism a part of who they are?

  5. Sadly, I recently have begun to write these people off. I do not expend myself educating them. I assign responsibility to their peers. And, I notify their leadership. I cannot trust someone who is unprofessional to make life and death decisions. I struggle with the 'grown-ups' in the medical field who demonstrate unprofessionalism also. If you know that a particular married surgeon, is screwing his assistant, does that mean that you should not refer a patient to them, does that make them "professionally" handicapped? Would you want to join forces in a research relationship with them, if they can't demonstrate loyalty to the core people in their lives? I just effing write them off. I am cynical this week, and there are too many darn good people out there to make up for their cr+p. xoxo


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