Reflections from a Clinician-educator at Grady: The Hard Question (not questions)

"Tell it like it is. . . .
Don't be afraid--
to let your conscience
be your guide. . ."


from "Tell it like it is" as sung by Aaron Neville

"Would you allow this person to participate in the care of a loved one?"

A simple enough question, right? One would think. But that question has recently changed the game for many of us clinician-educators at Grady. My friend and fellow Grady doctor, Erica B., directs our Internal Medicine clerkship and oversees the medical education in our department. Under her leadership, this question was added to the evaluation form that we use for the medical students. When I first saw it, I thought, Wait, huh? I must admit, that initial introduction to "the question" made me go back and reread my entire evaluation.

That question. That simple little question. It sneaks up behind you and taps you on the shoulder saying, "Are you sure about that?" snapping us all (or at least me--I'll speak for myself) into reality, whether we like it or not.

It's not asking the questions that often cloud our judgment. . . . like:

"Do you like this learner?" (Adore her!)

"Was this learner memorable?" (Unforgettable!)

These fourteen pesky words tacked onto the end of our forms have really put our feet to the fire. (Thanks, Erica.)

As I've said before: This job is about people and relationships. So, generally, we all make every effort to get to know the students and residents with whom we work. With very few exceptions, that has led me to like the vast majority of them. While I'm proud to admit, I'm generally not a "grade inflater," this new question has help me to put a lot of things into perspective. Like, sometimes a student or resident tries very, very hard, and is tremendously earnest in their desire to do well. It's hard to not pass someone like this. . . . . but at the end of the day, depending on their level of training, would you want this individual caring for your loved one. . . .or better yet--you?

It's no surprise that this inquiry is incredibly telling. In fact, Erica B. has even given presentations and done scholarly work surrounding all that they've learned from just asking this of the evaluators. Now we're forced to acknowledge what an awesome responsibility we've been given. Everyone is relying upon us to work closely enough with these future doctors to be able to make honest assessments of their progress. Your mom and my dad and someone else's sister is banking upon my evaluation of this person who could ultimately be the one standing over them in a life or death situation. Did you see some fleeting thing that worried you about this person in the role of lifesaver? Well?? Did you??? See? Erica B. was right. It all comes down to that question. Case in point:

Several years ago, I worked with an intern who was fun. Very fun. His comic timing was perfect, and he was extraordinarily likable. I enjoyed working with him and liked him very much. He seemed to respect me immensely, and it showed. But there was a problem. He was a rusher. Nearly everything he did in the hospital was hurried which translated into missing things. Fortunately, our system allows for checks and balances but when our service got busy, as inpatient services often do, there were definitely a few "near misses." Even though this intern was smart, and funny, and even deferential towards people like me, he only did the bare minimum. This sloppy work tendency was a problem--a major problem.

"Dat'l'do" (short for "that will do," in case you missed it.)

Being cursory when it comes to taking care of human beings is fraught with peril. I mean, who wants the doctor caring for them or their loved one to be anything other than meticulous? "Dat'l'do." That's what my dad calls anyone who does things half-way (or "half-assed" if you want to keep quoting my dad) and who doesn't take real pride in their work product or those affected by it. It's doing just enough to get by--and forget going above and beyond. "He's 'dat'l'do'," my dad would probably say after hearing about such a person (or perhaps he'd say "half-assed"--but keep in mind, those are Dad's words, not mine.)

After several oversights--"Did you realize that no one wrote an order to not let Mr. Murphy eat before his surgery this morning?"-- and many feedback sessions-- "The consequence of letting him eat is that his surgery was cancelled. It's critical that we all prioritize what needs to be done before leaving for the day." "Oh, my bad, Dr. Manning."-- I found myself staring at the computer screen, completing his electronic end-of-the-rotation evaluation. As I clicked the mouse through every objective question determining my take on his patient care or professionalism or ability to learn from mistakes, I grew more and more weary. Eeek. Was his performance satisfactory? Was it? I mean, sure, it wasn't like he was stellar in terms of completing tasks, but on this 1 - 5 scale, '3' says Dr. Manning thinks it was "satisfactory." Was I really, truly satisfied with the fact that he left three times without checking in on a sick patient or with the lab result that he forgot to check or the patient that he promised to come back to explain a plan to but never got around to it? Well? Or better yet, would I want him participating in the care of one of my loved ones?

The answer was, unfortunately, no. No. I wasn't satisfied, and, no, his work product that month wasn't satisfactory. (Erica B.'s question sure would have helped me get to this decision a lot sooner.) I remember agonizing over this evaluation. This was early in my career, and it would be my first time "failing" someone--and I felt terrible about it. Part of me was tempted to fill out the failing evaluation and just avoid him for the rest of his residency. Since I'd personally experienced and beared witness to these kinds of "sucker punches" in my own training, I knew that approach wasn't cool. He deserved to hear this face to face, and not during some annual meeting with his program director 4 months from now. I owed it to him to tell him the truth. . . . . and I owed it to my loved ones, too.

"Tell it like it is."

It isn't as easy at it might sound. Perhaps when the errors are horribly egregious, I guess someone could slam their hands down on the table and growl in exasperation, "You will NEVAH no not EVAH be a doctor!!" or, at least in this kind of over-the-top situation, Erica B.'s question wouldn't be so difficult-- "Take care of my loved one? I don't THINK so!" But the truth is, most times it isn't that straightforward. The unsatisfactory learners often cloud your judgement with likability or their own complicated "situations." To quote Dad again, this job "ain't nothin' to play with."

I sat down with him in a quiet room. No distractions, eye level, face to face (as any respectable clinician-educator meeting with a learner would.) "Let me give you some feedback," I started out. My division director, Dr. Branch, taught us to start off all feedback with the word "feedback." It supposedly puts folks on alert that this is not just any old conversation. It says, "This is the real deal, buddy. I'm giving you the scoop on how you did." Yeah, let me give you some feedback. So far, so good.

Armed with all that Dr. Branch taught me, I went into as many specifics as I could. I explained my concerns with the multiple things that he overlooked, missed, and omitted. I jogged his memory about the times when the resident or I had discussed these issues with him and offered suggestions on how to get more organized, that this had not led to a satisfactory improvement. "I'm afraid I have no choice but to give you a "marginal" evaluation. I just can't say that you are performing at a satisfactory level in these areas, or overall on this month for your level of training." There. I did it.

I held my breath and waited for him to scream in protest. Instead, he dropped his head and sighed. "I'm sorry for letting you down, Dr. M. I really am. I just. . . I just have trouble staying organized sometimes. I look up and the whole day is gone and I feel like I'm only through half of my list. Then the resident does everything I didn't get to, so. . . . .I guess I got used to it." He was tearful, and from his quivering lower lip, surely he was being 100% genuine. You suck, Manning. How can you fail him when he's sorry for letting YOU down? Arrrgghhh! No. . .do not wimp out. Do not!

I shifted nervously in my chair. Be helpful. . . not mean. Be honest. . . . not fake. We talked for nearly an hour about why he felt so distracted, and some more specific ways to help him refocus and get more efficient. He listened carefully, and never once challenged the things I said. It surprised me to see how receptive he was to my words. He was far more comfortable than I was with the whole exchange. I learned that he wasn't just being lazy, and that this was a problem with many layers. An intern with some serious organizational deficiencies had been paired with co-dependent micromanager resident--a recipe for either many near-disasters or a sho' nuff disaster the minute things get busy (as they often do.)

"Look," I responded softly, "this isn't about me--so don't worry about letting me down. The hardest part of this is that I really like you, and truthfully, I think you're capable of more. For that reason it's unfair to you to let you go forward this way, you know?" He sniffled and nodded without looking up. Oh my gosh. Is he crying? Wow, you suck, Manning. Congratulations on officially traumatizing a brand new doctor. Bril-liant.

"Yeah. . . . ." he responded rubbing his stubby hand through his hair, "I know." He let out an exaggerated sigh and rubbed his eyes with the palms of his hands. "Listen, Dr. Manning. . ." I raised my eyebrows in attention. "Uhhh. . .thanks. . . .I mean. . .I appreciate you caring enough to tell me all this. Really. I know it wasn't easy."

Whew! He had no idea how relieved I was that he didn't flip the desk over like that lady on The Real Housewives of New Jersey (oh, admit it, you've watched it!) In addition to this being the first time I had ever given an unsatisfactory overall mark to someone on my team, it was also my first time just giving not positive (see how afraid we are of the word "negative?") feedback to someone "straight with no chaser." I could hear Aaron Neville's shrill voice in my ear--"Tell it like it is. . . ." I think his coaching helped a lot that day. You see, up until then, I'd always used this technique that folks in medical education call the "sandwich" method. You sandwich a not-so-flattering remark with two flattering remarks. Most learners see it coming a mile away:

"You have amazing ironing skills! I've never seen such a perfectly starched lab coat!" (the top slice of bread)

"Oh, you are pretty much an assassin." (the bologna or "baloney" )

"Do you use Pantene on your hair? It has amazing body and shine!" (the other slice of bread)

(Now that I think of it, seems like the "baloney" is usually on the outside of this sandwich, but that's just my opinion.)

Anyways, I once heard an expert say that the goal of feedback is to 1.) teach the learner something, and to 2.) bring out the best in him or her. If indeed that's the case, I can't see how dancing around the issue helps. Deep down, I knew that this was true for this situation. I really wanted to teach him something and I wanted this learner to be better. I really did.

I looked across the table at him and smiled. "You know what? For me, a lot of things come down to the 'my mama' or 'my daddy' rule. When I'm faced with certain decisions in the hospital, I ask myself 'What would I want for my mama or my daddy?' It puts me back on track, you know? Makes me look up something I'm unsure of, call help when I need it, or turn around and go back to see someone on the ward when I'm already in the parking garage." He didn't say anything, but he nodded slowly. I think he got the point.

My mama and my daddy

"Would you allow this person to participate in the care of a loved one?"

This is what it all comes down to. Not about me liking you, or your lovely penmanship. Whether I like it or not, when I give the green light to a resident or a student that gives me real concern, I'm letting down more than that learner. I guess the reason I'm blogging about this today is that I'm just realizing more and more how much is at stake. And listen--I'm not forgetting my other responsibilities in this crazy medical upbringing either. I'll make every effort to get my students and residents to a place where I can say "yes" to the above question without batting a lash. I'll spend that time doing extra sessions with the students or helping a resident come up with a plan in clinic or even shadowing someone to see where they can improve. But if for some reason, after giving my very best effort, that learner is not where they're supposed to be--I'm going to tell the truth about it. To, as that expert said, "bring out the best and teach," yes. But even more because my mama and my daddy (and several other folks' mamas and daddies) are counting on me to "tell it like it is" -- and shield them from anything or anyone "dat'l'do."

"Tell it like it is" as performed by Aaron Neville and the Neville Brothers
(and joined by Greg Allman and Bonnie Raitt--pretty gnarly stuff!)