Category: Informal-curriculum

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Informal-curriculum Nonfiction Observations

Name-calling.

Let me start by saying that it actually doesn’t happen that often.

The yelling and screaming usually comes from men who aren’t under my care. It often happens when I’m talking with my patients or when I am just walking past a cell block.

Sometimes, it is repetitive yelling that sounds like a metronome:

WHORE! WHORE! WHORE! WHORE!

Sometimes, it is a tirade:

F-CKING SLUT, you’re a F-CKING SLUT, d-mn whore, F-CKING C-NT, YOU HEAR ME? YOU’RE A F-CKING SLUT, YOU F-CKING B-TCH, yes, YOU, you’re a F-CKING BITCH…

Other men take issue with my short hair and assert that I am a lesbian:

You’re a LESBIAN, aren’t you? What the F-CK is wrong with you, LESBO? Why don’t you like dick? F-CKING LESBIAN, you and your F-CKING SHORT HAIR…

For reasons I don’t understand, it is uncommon for men to yell racial slurs at me.[1. No one in jail has yet to call me a “chink“—at least not to my face or when I am in earshot. I did have a patient who would intersperse his sentences with musical phrases: “Ching chong ding ding ting tang…”. He didn’t do this with anyone else. He also refused to believe that I am a physician. He insisted, “There’s no way you’re a doctor. Women can’t be doctors. You’re probably just a clinical assistant. Women aren’t smart enough to be doctors.” I steered the conversation elsewhere.]

I have since learned that those men who yell synonyms for commercial sex workers at me or insist that I am a lesbian become more enraged when I ask them to stop yelling. Usually it goes something like this:

Maria: “Hi. Could you please stop yelling for ten minutes so I can talk to the guy over there? It’s hard for me to hear him.”

Inmate: [spewing more hatred at a louder volume and a greater frequency]

This response differs from other men who yell for different reasons. Often the men who scream about the crimes of the government, the arrival of the aliens, the ghosts in the machines, and the coming of the Antichrist will acknowledge my request and kindly stop yelling. Some can’t stay quiet for more than three minutes, but they try.

On occasion, the men who are my patients—and sometimes these are the same men who proclaim that they are actually machines and not humans, or they can’t string together coherent sentences—will scream past me to the men yelling malicious things: “SHUT THE F-CK UP!”

Their imperatives often go unheeded.

Hearing this vitriol doesn’t bother me too much. I mean, it bothers me enough to write a blog post about it, but such behaviors make me wonder more about the suffering of these men. Perhaps these men are screaming at me because I am on the other side of their cell doors and they feel anger with their lack of freedom. Perhaps these men don’t like the inherent power differential between them and me in a setting like the jail. In an effort to assert dominance a man may shout misogynistic things at me because he is trying to close the gap between his status and my status. Maybe women in his past have done terrible things to him.

My male colleagues have mentioned that these same inmates might insist that they are gay. Otherwise, most of the commentary these men lob against my male colleagues are death threats. This is in contrast to the threats I receive; men usually threaten to rape me. (Let’s be clear: Such threats are rare.) And it is not necessarily the men who scream hateful things at me who threaten rape.

What people say and what they do aren’t always congruent, whether in the jail or elsewhere. Consider the men in jail who have been charged or convicted many times of sexual assault. They may never shout anything at female staff. Some of these men show great courtesy; they look me in the eye; they say “please”, “thank you”, and offer gracious social smiles.

One wonders what they do not say out loud.

Some people will judge you just based on how you look. To some men, women are malignant deviants; they induce fear and loathing. Some men decide that the best course of action is to hurl hatred at women.

Sometimes, they might do even worse things.

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Education Informal-curriculum Lessons Medicine Systems

Negotiating a Job Offer (introduction).

I recently gave a talk to psychiatry residents about how to negotiate a job offer.[1. The focus on the talk was on negotiating a job within an organization that is already established—a “typical” job for a physician. There is more flexibility—and uncertainty—for start-ups and other innovative programs that deviate from standard models of medical practice. For those of you who are trying/creating something new and different, good for you: We need you.] Our resident cohort did not receive any formal instruction about this[2. When I was a resident a few attendings in private practice did talk with us about how to hang up our own shingles. Most of the people in my cohort did not go into private practice.] and I don’t know if this is a topic that is common in resident education. It seems that physicians, as a population, aren’t skilled in negotiating job offers.[3. I wonder if physicians don’t think or learn about job negotiation because of our training experiences: To get into medical school we learn to jump through various hoops that others set aflame; we learn how to sit through interviews, though we’re rarely in a position to ask for what we want; we cannot negotiate where we go for residency; we are usually unable to negotiate the finer points of our clinical rotations; and, by the time we complete our residency training, we’re relieved to have more freedom and salary than we did as trainees, so we don’t ask for anything more.]

My suggestions for negotiating a job offer may not be comprehensive, though I hope that they will help new graduates and “early career” physicians have more confidence and skills when talking with potential employers.

I’ll write about two items of information candidates should always ask employers for. Most candidates don’t ask for these two items, though they can clarify the job, set expectations for both employer and employee in the future, and provide ideas for negotiations.

I’ll also share a list of negotiating items that are particularly relevant for physicians. Given that each specialty in medicine has its own practices and culture, consider the list a starting point.

Lastly, I’ll suggest general attitudes and perspectives that candidates (particularly women) can hold during the negotiation process to make it less daunting. Expect some cheerleading.

A caveat to begin: Do not start negotiating until a job has been offered to you. Even though you might burst with excitement about the job and believe that you are well suited for the work, the employer may not share your sentiments. Negotiating details of a job before it is yours is foolish. Imagine if the tables were turned: You’re sitting in an interview and you don’t want the job. Meanwhile, the employer is saying things like, “So… could you work every Thanksgiving, Christmas, and New Year’s?”

The interview process is your opportunity to ask questions, watch how the employer is behaving (because the people talking with you should be on their best behavior), and learn if you, the work, and the employer are a good enough fit. Though the employer initially has more power (as they are offering you a job, not vice versa), that doesn’t mean you are powerless: All the things you learn during the interview will help you decide whether you will accept their offer. And maybe there are some things you’d like to be a little bit different before you agree to work with them. That’s what negotiating is about.

Next post: The first of two things you should ask for during the interview.

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Education Informal-curriculum Lessons Medicine Observations Reflection

Guiding Principles for Medical School.

Dear Jane:

Thank you for asking me about my perspectives on medical school. Here are some general principles that you might find useful in your own training:

View everyone as your teacher.

Everyone you encounter will teach you something. Be open to what they have to offer.

Yes, your professors and attendings, the “official” teachers, will educate you. Patients, however, will often be your best teachers. Listen to what they say, watch how they react to what you do, and acknowledge and accept the feedback they give to you. Their teachings are often the most useful and valuable.

You might see a physician condescending to a patient and decide that you never want to do that. You might see a nurse offer quiet comfort to a patient and decide that you want to mimic that manner. You might witness a technician help a patient feel less anxious before a procedure and decide that you will steal that technique. You might talk to a physician on the phone and decide that you will adopt that professional and kind manner when you talk to other physicians.

In this way you can be a student for life.

Reflect on your experiences every day.

This can take many forms: You can keep a journal. You can talk with friends. You can meditate. You can go for a ten-minute walk around your neighborhood. You can sit in a chair and stare out the window. It doesn’t have to be a big thing.

Reflecting on your experiences will help consolidate what you learn so you can apply that knowledge in the future. This applies to “book” knowledge (physiology, pharmacology, etc.) and “non-book knowledge” (how to redirect a patient or your colleague, how to manage your emotions in the face of disease and death, etc.).

There will be times when you will feel overwhelmed and cannot or choose not to reflect. That’s okay. It happens.

You will see terrible things.

You will see people suffer. You will see people die. You will hear hospital staff say derogatory things about patients. You will see your colleagues lie about things they should not lie about. You will see everyone—the patient, nurses, doctors, technicians, family members—work as hard as they can and none of it will help the patient. You will see people who need help, but don’t want it.

Remember the discomfort you feel when you see things you don’t like. These experiences are your teachers, too. They will help you stay human and humane. Medical training can steal that from us.

You will do terrible things.

You yourself will do things you will not like. (Hopefully infrequently.) You will snap at patients. You will be snarky to staff. You will bend the truth, if not lie, because you won’t know what else to do.

You must reflect on these events so they don’t become habits.

Connect with physicians who do not work in academic centers.

Some physicians in the community will have practice patterns and work in systems that will appall you. Some will inspire you. While academic medicine does happen in the “real world”, it’s often different from what is in the community.

Exposing yourself to the non-academic world will help you learn about a greater variety of patients, creative and innovative developments in health care, and provide more context about medical care in the world. Even if you end up working in an academic center, these experiences will shape your practice.

After you decide what kind of doctor you want to be, take rotations in every other specialty.

Medicine is compartmentalized, but people are not. Your patient with high blood pressure may become pregnant… develop a painless red eye… fracture a bone… have her gall bladder taken out… or develop an alcohol problem. Learning about a variety of conditions will help you take care of people, not just diseases.

The most useful guiding principle for me during my training (and now) is to remember that your work is to take care of the patient. It’s not about the letters after your name, long titles, or how big your salary is. Medicine isn’t about you. It’s about the patient. That attitude will keep you humble, curious, and grateful.

Congratulations on your admission to medical school! May you find the work rewarding and meaningful.

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Consult-Liaison Education Informal-curriculum Lessons Medicine Observations

Informal Curriculum: Lesson 1.

It’s been over a year, but I haven’t forgotten about the Informal Curriculum.

The first recommendation in the informal curriculum in medicine, which I still believe is “paramount, the most difficult to define, and often challenging to implement”[1. It is no coincidence that a topic that is “paramount, … difficult to define, and … challenging to implement”, is also difficult to write about.] is to be a person.

What does this mean?

Be the best professional person you can be. Be a person who actively listens to patients, who shows empathy and emotions. Be courteous. Show humanity. Be a person.

Non-psychiatrist physicians seem to have an easier time with “being a person” than psychiatrists. Psychiatrists, as a population, can be weird. We can demonstrate exceptional skills at not being people. Sometimes we come across as intrusive, awkward, and odd.

I get it. I’ve had peculiar interactions with psychiatrists who knew I work as a psychiatrist. That might explain why the conversations were even more uncomfortable than expected. (Those are stories for another day.)

Do note that this recommendation exhorts you to be a professional person. This doesn’t mean that you tell your patients about your relationship or health problems, how crappy of a day you’re having, or why your political views are correct. That stuff makes you a person, too, but that doesn’t make you a professional person.

If patients are telling you things that worry them, be a person and acknowledge their worry. If they tell you something funny and it’s not inappropriate to laugh[2. Being a person does not mean that you toss clinical judgment and boundaries away. There are times when you shouldn’t smile and laugh, even if you want to. That topic is beyond the scope of this post.], smile and laugh. Talk with them like they’re people, not diseases or case studies.

Be a person.

Patients often want to share a connection with their physicians. Patients suffer and worry. They want to know that you care about their suffering or worry. That’s what actual people[3. Yes, there are anecdotes that people will share their woes with and find comfort in a computer program.] do: They care about the suffering and worry of others.

Be a person.

Why is this paramount? Why is this my first recommendation in the informal curriculum?

Because relentless forces exist in medical training and work that can transform you into a non-person.

You use words that most people don’t use. Most people don’t talk about MELD scores, Glasgow Coma Scales, or HIV classification systems. You see a lot of emotional and physical anguish. You see people who are ill. Sometimes they cry. Sometimes they scream. Sometimes you see parts of them that they will never see. Sometimes you see them die.

These are the things that can make you turn into a non-person.

So make an effort every day to be a person. If you’re not, none of the other suggestions in the informal curriculum will matter.

Categories
Consult-Liaison Education Informal-curriculum Medicine

Difficult Interactions (III).

(Note: If you found the previous posts in this series “woo woo”, you might find this one nearly intolerable.)

A final reason to stop talking in the midst of a difficult clinical interaction is so you can accept what the other person is doing.

When you accept someone else’s behavior, this does not mean that you necessarily agree with it. It doesn’t mean that you condone it, support it, or want it to happen more. It just means you accept what is happening.

We cannot control the behaviors of others. We can influence them, but we cannot control them. If we do not accept what is actually happening, we have no chance of influencing what happens next.

I worked in a residence where two men would occasionally pee in the elevator. They weren’t incontinent, there was no Foley catheter and bag that malfunctioned… they just periodically voided their bladders in that small space.

Willfully ignoring the yellow puddle in the elevator won’t resolve the problem. The odor would fill the elevator and other people would inadvertently step into the urine.

Wistfully wishing that they had voided their bladders elsewhere won’t resolve the problem, either. “Why didn’t they use the bathroom? If they really had to go, they could have at least peed into the plant next to the elevator. Should they wear adult diapers?” Trying to solve the problem before having a clear definition of the problem often only leads to frustration. You cannot define a problem until you accept that it is a problem.

It’s also common to realize that, when you’re silent and accepting what the other person is doing, the difficult interaction often softens. It is hard to argue with or resist someone when he is accepting what you are doing and saying in that moment.[1. It takes two to fight, two to tango, blah blah blah….] Furthermore, you are also practicing and modeling a useful skill. The other person might realize that he could use that skill at that moment, too.

To review: One reason why it is useful to stop talking during difficult interactions is so you can acknowledge the emotions you are experiencing. Another reason is to recognize and adjust the language you are using to describe the situation to yourself. A third reason is to accept what is actually happening so you can plan and take next steps. It seems like all of this would take a long time and result in awkward silences, but that doesn’t happen. For many people, staying silent isn’t a habit. It takes practice.