Wednesday, September 19, 2012
Life at Grady: Runners and gunners
A person who is competitive,overly-ambitious and substantially exceeds minimum requirements. A gunner will compromise his/her peer relationships and/or reputation among peers in order to obtain recognition and praise from his/her superiors. (courtesy of urbandictionary.com)
She was standing there in front of me, shuffling a stack of photocopied medical records. Her glasses kept slipping down her nose, partly because of their size but mostly because of the thin film of perspiration covering her face. The tremor in her hands seemed more pronounced because she was holding those rattling papers. I put on my most reassuring expression to help her relax but it wasn't working.
I suppose the whole thing was a bit nerve-racking. I mean, here she was a medical student presenting a patient to the attending on her first week of the Internal Medicine hospital service. At Grady Hospital, no less. For whatever reason, this rotation--along with Surgery--are the ones that bring out the most nerves and insecurity in students. I think it's because they are considered by many to be the "bread and butter" of everything else in medicine.
It was also a pretty big team that month. A senior resident and two interns, of course, but also three additional students not counting her. One was a fourth-year who was nearing the end of residency interviews. He'd already decided on a career in Radiation Oncology and that fact, coupled with his experience, made him the most at ease of the medical students. Another student had been off-cycle after earning a PhD. This was one of her final rotations so she, too, was mostly confident on rounds.
Then there were the other two. Seth and Parul. Both had just started the clerkship and were clearly neophytes when it came to the hospital service, but that was where their similarities ended. Seth, the one who wasn't presenting at the time, had enough swagger for every member on the team. He was smart--and he knew it. All others in his presence had one choice and one choice only--step your game up or get your game stepped on. I liked how bright and enthusiastic he was but there were times that it seemed like he broke the code of "what's cool" when it came to his fellow learners. I didn't know how to feel about that.
Parul was pound-for-pound just as smart as Seth. I'd had a few brief encounters with her during the pre-clinical period and knew from those interactions that she was wicked smart. Somehow I'd gotten wind of the fact that she'd come to medical school on an academic scholarship and that she'd stealthily knocked nearly every test--including the boards--clear out of the park. Interestingly, she kept all that mum. No one would know how well she was doing from casual interactions because her confidence had it's "near empty" light on just about every time you saw her.
So on our morning rounds, Parul walked bumpily through her patient presentation and it was mostly bumpy because she inserted an "um" between every other word. Otherwise, her information was well organized and quite fluid.
I make a point of treating the students as real, true clinicians and members of the team. I ask them the same management questions as I'd ask the interns--particularly when it comes to their opinion of what to do next. Parul's plan--though um-filled--was wrapped pretty tight so I didn't have too many questions at the moment.
"What do you make of the acute kidney injury?" I asked.
Her face quickly flushed and she swallowed hard. The pregnant pause was awkward, so again, I did my best to allay her nervousness. Finally, she parted her mouth to speak, but just as she did Seth spoke.
"Didn't you mention that she takes a diuretic? The hydrochlorthiazide could explain the AKI."
Parul cleared her throat and offered Seth an anemic smile. Instead of looking at her, he smugly looked at me to see what I'd say next. The resident started to say something about the diuretic but I put my hand up to stop him. With my attention on Parul, I nodded in her direction.
"Well," she started, "I did, um, consider the thiazide as a possibility. She was prescribed this three months ago, so that is a consideration."
"She's also hypercalcemic." We all looked at Seth who added this little pearl of information while holding not even a single sheet of paper. "The HCTZ could cause her some decreased calcium excretion, too."
I tried not to look annoyed with Seth but I was. I turned back to Parul and made myself more clear. "I want to know what you think, Parul. What are your thoughts?"
Again that lumpy silence as she carefully sifted through her words. And then, she put her own pieces together.
"I am not so sure about the thiazide, Dr. Manning. She wasn't taking them because they made her have to urinate too often and she catches two buses. I counted out her pills and the bottle was just a bout full. And it was dated from two months ago." She looked around with trepidation and then continued. "She is hypercalcemic--as high as 10.6--but I saw in her records that this preceded the hydrochlorthiazide."
"Okay," I said. "So what else did you find out?"
"That she's anemic," Parul quietly reported. "Her colonoscopy was negative and she was borderline iron deficient. She also had proteinuria on her urine dipstick in the ER and an unusually high protein against that albumin level."
"So you're thinking multiple myeloma? Makes sense." Seth had jumped in again. I sucked in a deep breath in the most subtle way I could. What I really wanted to do was grab him by the collar and tell him how uncool it was to steal her punchline like that.
"Well, duh!" I chided him. "Obviously that's what she's getting at. What's up with you jumping in on the punchline, dude?" I couldn't resist saying something. He laughed but still looked uber-confident.
"So, if it's okay with you, I think a serum protein electrophoresis might be indicated," Parul went on.
"Makes perfect sense," I said and smiled at her, putting my hand up for a high five. She timidly met my open palm with hers. "Anything else?" This time I was glancing toward my resident and the rest of the team.
"Well, we could also check for HIV or hepatitis C," Seth mentioned. "That could also explain the gap between he total protein and albumin."
"Good thinking," Parul responded quietly.
"Has that been checked at all?" I had to know. I knew that Parul knew this patient well and was willing to bet that she'd already thought of this. She was such a good citizen that instead of neck rolling and fingersnapping in Seth's face like Honey Boo Boo, she simply smoothed it over by letting him look good--even though he'd repeatedly been doing so at her expense.
"They were checked, Dr. Manning. Both were negative."
"Got it. Thanks, Parul."
So we finished up our rounds and that same kind of thing played out two or three more times with Seth one-upping his comrades with these medical booms he repeatedly lowered on them. Every point he made was a good one. But the issue was how he did it.
I pulled Seth aside later that afternoon. I told him that I could tell that he was bright and that he enjoyed learning. But I also told him that he needed to be more savvy about how he interjected his medical knowledge while another had the floor.
"There's a way to do it," I told him. "You want to be collegial, you know?" So I gave him examples like the whole deflating interruption about multiple myeloma and his insistence on getting the last word on other discussions. "Be careful," I said. "Medicine is a team sport."
"So am I just supposed to stand by passively? Not speak up unless it's my turn?"
"No. That's not what I'm saying. Not at all."
He furrowed his brow and looked annoyed. Annoyed in that "you're really just insecure so this is why you're saying this and not because I was treating my classmate like an a-hole" kind of way.
He let out an exaggerated sigh and countered my statement. "Soooo. . . .if I hadn't mentioned the diuretic, I'm not sure it would have come up."
"Of course it would have. Seth, she was still in the middle of her assessment and plan. You never gave her a chance."
"I mean. . . .she was just standing there hemming and hawing. I'm here to learn. This is frustrating to hear because speaking up on rounds helps me to learn. I can't help it if no one else wants to speak up."
I paused and tapped my fingers on my lips before speaking. "It wasn't that you spoke up. It was how you did, Seth. It was how."
What happened next was something I had never done. I commenced to give him a series of suggestions--specific suggestions--for other things he could have done and said that didn't undermine his colleague. Such as looking in her direction when speaking. Or letting her finish her thought before jumping in. Maybe even asking her, in a collaborative way, instead of a way that trumped her thoughts.
But especially not sucker punching her with extraneous information on her own patients in front of the attending. Not. Even. Cool.
"She hadn't mentioned the calcium level. How did you know the patient was hypercalcemic?" I asked him. This was probably the thing that was making me the hardest on him. I had the distinct impression that he'd looked up the labs and prepared to share facts that Parul hadn't mentioned. All in an effort to look good.
"I look up all of the labs for all of the patients every day," he said. "I'd seen it the evening before so thought I'd mention it on rounds."
"Did you think of mentioning it to Parul that morning? Like in case she didn't know?"
He was quiet.
"That wasn't really cool."
"I guess I was trying to put the patient first."
"I . . .I mean, I just wanted to make sure we thought of everything. I thought me looking up labs and thinking about people other than just my patients would be helpful. Some call it being a gunner. I just call it trying hard and holding myself to a high standard."
I pressed my lips together and raised my eyebrows. I gave myself a five second countdown before speaking to make sure my words were chosen carefully.
"Look, Seth. I'm actually okay with 'gunner' medical students. I don't mind it when you're reading and going hard in the hospital--in fact, I welcome it. But be a gunner for the patients. Knock down doors to advocate for them and to get to the right diagnosis. You can do that and be collaborative with the people on your same team, you know? Gun all you want on my team. Just gun for patients. If you're gunning for the patients, you don't have to step on toes to look good. It's just a by-product of your efforts."
"I wasn't trying to step on toes." For the first time his voice was small.
"Whether you were or you weren't, you kind of did today. You could have shared your thoughts with Parul before she presented her patient. Or you could have waited until she finished the entire presentation. I always open it up for others to share their ideas at the end."
"Good." I reached out and shook his hand. "Medicine is a team sport. You got that?"
He nodded like he got it. Something tells me he did.
Later that week, I spoke to Parul and coached her on ways to be more confident in her knowledge. I commended her for counting those pills and reading the bottle dates. I also gave her props for data mining in the chart and thinking carefully about that patient. Then I told her some stories about people that helped me along the way in the confidence department.
"We're going to work on your confidence," I told Parul in closing. Because in medicine, that's important.
I guess I've been thinking a lot about coaching and encouraging these days. It makes such a big difference. Don't you think so? I do.
The rest of that month went really well. Parul and Seth worked well together and grew in their mutual respect for each other. They worked in concert and pushed each other to step their respective games up without tearing the other down. And that was a really, really good thing to witness.
It's funny. Confidence and competence are almost always mismatched in medical training and sometimes beyond that, too. On second thought, that's not really very funny at all, is it?
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