I was briefly at the "Young Practitioners' Forum," which is supposed to be how to get a fellowship, how to get your first trauma job, how to keep your first trauma job, etc etc etc. Anyway, I kept on having to leave for stuff, but while I was there I heard one of the traumatologists giving a talk on 'things that you don't think matter but actually do.' I've heard this particular traumatologist speak before and he's really funny and his talks are always entertaining, even if they're about nonunions or something. (I've seen him on webinars and I've heard him speak at courses. I have no idea what he's like in real life, but as a speaker, he freaking rocks.)
He said some stuff that i agree with, like never walk through your own waiting room late because then it looks like you don't care. Don't park your porsche in your patient parking lot. Don't tell patients you're going on vacation, say you're going to a conference. Stuff like that. He also said a lot of stuff that I try to do, like do your own dressing changes, which is something I always try to do myself. First off because otherwise I might never see the incision, and also because I think patients appreciate it. A guy who graduated a few years ago used to take the bandage off and write an order for the nurses to replace it and that drove me crazy. I mean, some attendings like Dr. Smile and Dr. Chatterbox take the dressing on postop day #2 and leave the incision open to air, but it seems really half-assed to me to take off a bandage and make someone else put another one on. Anyway.
He then showed a picture of a med student texting in the OR while the patient was being moved on to the operating table. If you've never done that, usually it takes a few people to move the patient, you need the anesthesiologist at the head (although I've done it once or twice) and then you need someone on either side of the patient and someone to get the feet. If the patient's really heavy, you need more people. So if you're in the OR when the patient is getting moved (and you should be), then you should be helping. PD once got bitched out for not helping to move the patient (he was doing orders at the time) and it even showed up in his mid-cycle evals that he wasn't helping move enough. So really, this is a little thing that has potential to be A. Big. Deal. My personal ritual is to do orders while the patient is waking up, help move the patient, and then thank everyone in the room and walk out.
Back to the story, the traumatologist said it was inappropriate and unprofessional for the med student to be texting when people around him were doing work. He then said that the med student had gone to him for a letter of rec and he showed the student the photo and said he wouldn't write a letter for him. The med student didn't apply to ortho.
There was a lot of murmuring around me after that story, the guy in front of me seemed to think that was excessively harsh and the guy behind me seemed to think it was appropriate, but I wasn't totally sure how I felt. Part of me kind of agrees. I don't think you should have your phone out in the OR. And unless everyone else's med school is very different from mine, it's almost impossible that he was texting anything important about a patient. (this would also imply everyone else is a different resident from me because I wouldn't trust a med student to do something important for me. I mean yes, I'd trust them to do dressing changes and stuff like that, but for the most part if it's important, then it needs to be done by someone who has the ability to write orders. Feel free to disagree with me) So then yeah, it looks like he didn't care about being helpful in the OR, which is a red flag. We had a med student last year who I thought was lazy and yes, I did say something when his application was being discussed because if you're lazy as a med student on an audition rotation, I don't want to be your coworker when you become a resident. But if it was a one time thing and he was texting then I don't think he deserves to lose the ability to be an orthopod over that. If it's a pattern, sure, but if he just happened to have his phone out, then OK, it doesn't seem like that big of a deal. Also, if you're a med student, it's not like you're doing all that much to begin with. The guy was probably bored after a long day of watching people do stuff. So yeah, he had his phone out, but if texting had been invented when I did my third year rotations (it was. I just didn't do it because it was back in the days when typing the letter C involved hitting 1 three times and really, that was a lot more trouble than it was worth for any message longer than "hi") I probably would have texted more.
So I have mixed feelings on the subject. I don't know what else the student was like. I guess he really screwed up in front of the wrong person though.
In the interest of full disclosure, I was once seeing a patient and she was looking away from me and talking with her eyes shut so I took out my phone to read a text and reply to it. She opened her eyes and looked at me and said "Oh. I'm sorry. I see you're busy." I still feel guilty about that because it was really inappropriate and unprofessional and actually just plain rude to text in front of her like that. I have never done that again, I do not answer my phone in front of patients unless it is that patient's attending calling, I do not read or answer texts in front of patients and for the most part, I do not pull out my phone in front of patients. I don't answer pages in front of patients either. Someone once told me that the most important patient is the one in front of you so really, I think everything else can wait. Otherwise it's pretty freaking rude. And apparently can cost you your dream. And i got really lucky that my patient never told anyone because i definitely deserved to get in trouble for that and I didn't.
That is too harsh.
ReplyDeleteHarsher yet, failing someone due to poor attendance ( presentations and seminars) because the don't check their mobile while in clinic or OT to see if a class time have been changed. Doctors who suppose to mentor us get busy with serious staff and we had to postpone and get another time whenever ( suddenly) he /she can spare some time.
I feel sorry for that student.
It is not uncommon for surgeon ( or other humans) to judge people based on one incident.
I think it's totally appropriate. It's not just that the student was texting -- s/he was texting enough or annoyingly enough that someone bothered to take a picture AND the student didn't notice them taking a picture AND this happened while on an audition rotation. The amount of self-important you would need to be for all of those pieces to be in place is unbelievable. This sort of med student will not only grow up to be in the sort of resident that the nurses hate, all of their coresidents will too, because this will be the person who is always too busy for a call trade, never helps the night team when on days or vice versa.
ReplyDeleteIs it just one incident? Not really -- let's say the kid was waiting on an important e-mail from school or a mentor or a family medical emergency. A. S/he's not the only person in the OR who's getting important messages, so to act like s/he is/their messages are the most important is pretty arrogant. B. If s/he is waiting on something truly emergent, the correct way to handle it is to say "excuse me, I'm so sorry, but I really need to check this because it's an emergency" and C. If it's not emergent, to check in a more discreet way (check before you go in to the OR; go to the "bathroom," check between patients, etc.)
Taking a photo doesn't take a split of a second and I know a truma surgeon consultant who took photo of his student in OSCE and post them in Instagram without thier consent. Do we got to judge him based on this incident? He is attached to his phone but he is an amazing person and teacher.
DeletePlus some surgeries are more than 1.5 hour too long to focus especially if you are only observing or you had too be thier and that was your 5th lap chole in your first week
Most importantly, one expect his mentors to guide him. I think it is part of the that surgeon job to point that to the students and warn him. It is so unprofessional to take your phone and snap a photo like that by the way.
I feel frustrated when seniors forgot they were students. 8 of my colleagues had to due the whole year for things if seniors were kind enough will voulnterly point out and correct. That is part of the medical oath.
4th year med student here... Would just like to point out that it is so easy to be oblivious as to what is appropriate or not as a clinical student when you're changing rotations month to month. I had no idea I was expected to help move patients on my first surgical rotation because I was never outright told to... Until my resident got frustrated and chewed me out for not helping. It's so easy to forget what it's like being a brand new clinical student and having to figure out your role and what the team expects of you without being annoying or appearing clueless and irresponsible.
ReplyDeleteBingo. Although, if this was more than half-way into the rotation and he hadn't figured that out, he's probably not smart enough for ortho (or, maybe self-aware enough to be a doctor)
DeleteThis comment has been removed by the author.
DeleteI think this is another symptom of medical hierarchy and the demand for 100% selflessness 24/7. That said, yes it's important to help out when there's work to be done. However, rather than humiliate the med student or use the photo (which, I assume, was also taken with a cell phone--note the hypocrisy), perhaps it would have been instructive to pull them aside at the moment and express how it makes them look to others. But no--this is medicine, where constructive criticism is a rare oasis in a desert of harsh judgment and condescension
ReplyDeleteWas the med. student right or wrong? More to the point, what is the long term impact of this "no mercy" rule on people who are going to be caring for the sick?
ReplyDeleteMy instincts tell me, not a good one. NeuroTrumpet mentioned that he hadn't
had a sick day since having walking pneumonia in this third year! Peace is
being asked to push through the flu! You're all kidding, right? Yes, the med student is guilty of poor judgment in this instance. However, could the event
not have been used a learning tool rather than you're done! Perhaps the
med student will incorporate this thinking as a way of doing business when
he has the upper hand. And so on and so on. Where does it all end?
Not in a good place, I'm afraid.
- Paul
As a fourth year medical student, I would like to point out that this discussion of right and wrong on the student's part presupposes that the student was ignoring the patient and texting just because his cell phone was out. I have had experiences in the OR while not scrubbed in on the case where attendings or residents ask me to look something up right then (which I can usually do in a matter of seconds on my cell phone), or even ask me call/text other residents about things to do. If the attending happened to walk in at the right time or not hear that request it would be all too easy to think I was not paying attention rather than following instructions. Medical students serve a lot of masters, and I have a hard time thinking that a student on an audition rotation would willfully show a lack of interest.
DeleteThank you, I was just about to point this out. I keep a lot of notes and references on my phone. Unless I had the whole back story I wouldn't have assumed the med student was texting, but looking something up related to this particular case. I know of one particular med school where they give everyone iPod touches for that exact purpose. Had I been that med student I would have been miffed at the old fashioned thinking, and not even having a chance to explain myself. I probably also wouldn't have applied to a residency that was so quick to make incorrect assumptions about me.
DeleteAs a former med student and current physician, I should point out that no one is entitled to a reference letter; it should be earned. And usually, people decide to write a letter on your behalf if they were impressed by your overall performance - if not, they really don't have to write you a letter. In this case, we only heard about the photo, but presumably the student asked the orthopod for a letter because he was his/her supervising attending, and the orthopod took the incident as a part of a whole assessment of the student's performance - i.e. this wasn't an aberration in an otherwise strong overall performance, but likely a generally unremarkable student who, as orthochick pointed out - failed to perform well during an AUDITION rotation. Also, i'm sorry, but its basic common sense not to text as a medical student in the OR.
ReplyDeleteIMHO this was probably too harsh. At the same time, the attending did the student a great favor by refusing with a specific reason, rather than agreeing and then destroying him in the letter.
ReplyDeleteI have never found a physician who could dress a wound so that the dressing stayed on for more than 5 minutes - and, don't get me started on the best way to anchor an A-line. It takes a nurse to know these valuable skills.
ReplyDeleteIf you are in the OR - or ED - while we are moving a patient, and you are standing there doing nothing, you might just get stepped on, accidentally on purpose. Or, you might be the one to get called at 3 a.m. for that CVA admit from the nursing home that needs an H&P. The fact that you are not jumping in to help will not go unnoticed. (As you know, we nurses can make or break your rotation.) TCG RN
So, what I'm really hearing is that nurses are delusional ("it takes a *nurse* to know these valuable skills"), vindictive ("We nurses can...break your rotation."), and enjoy physical violence ("You might just get stepped on...on purpose."). Niiiiice. Way to be professional and rep the profession!
DeleteI can't speak for TCG RN, but the subtext or music as I call it seems to say, although I am not treated as a valued member of a team, I have valuable skills too! Perhaps TCG feels stepped on by others in the medical profession and is asserting that I can do the stepping too!
DeleteMy sense of it: TCG is feeling undervalued and is responding in kind. Personally, I see all of you, physicians, nurses, NP's, PA's,Paramedics, etc. as valued members of a team, racing down a hospital corridor together in pursuit of a patient who needs your attention. Yes, your clothes may look slept in, your faces tired and perhaps one or two buttons on your shirt/blouse are open. And in the right light, you can see the Superman/Superwoman logo jutting out from underneath!
- Paul
Mea culpa, mea culpa, mea maxima culpa. How easy to forget that when writing, your readers cannot see your tongue firmly planted in your cheek.
DeleteTo set things straight. In my entire, lengthy nursing career, I have never felt undervalued or vindictive and I deplore violence of any sort. I have never been accused of being unprofessional. I am honored to be very well-respected by physicians, nurse colleagues, and patients and I am often the one sought out for particularly challenging or difficult cases. I stand by my statement that that I have had to re-do more dressings applied by doctors than those applied by nurses. Maybe nurses think more about how the patient will be moving and what the stresses on the dressing will be, but we have had so many dressings done by doctors fall off that it became a running joke between the nurses and the surgeons. That's just my experience.
I would never, never intentionally step on or injure anyone. In fact, in the ICU or ED, med students are usually terrified and I go out of my way to help them and ease them into the chaos by teaching them. There are three types of med students (and first years) that bear watching: Those who are not frightened and think they know everything, those who don't pay attention at all, and those who act entitled. If someone is not paying attention, usually just saying "We could use some help here" is enough to bring them around. If, however, I need to say that to someone more than once, I might ask that they go elsewhere to hang around.
If they are acting entitled or like they know everything, it is true that we will probably not seek them out for an interesting case, a teachable moment, or to offer them extra help in the same way we would one of their peers; but I believe that is human nature. If someone gets stepped on, it will be by accident because they were too unaware to realize that people are running around madly in an effort to save a life. Nursing and medicine are too difficult to waste energy being mean or nasty.
I tried to be funny by being extreme. Don't worry, I won't do that again!
TCG, RN
These days, we can review medical records or look up information about drugs or study practice questions on smartphones. Obviously I wouldn't do that around an alert patient because they might not realize I'm doing something medicine-related, but I think most medical teams understand now that it's more practical for students to use their phones rather than stuffing their pockets with reference books. I think this student should have offered to help or at least paid attention, but I would cut him some slack if he hadn't been instructed on what to do during orientation because a lot of times as a med student it feels like the best way to help is to get out of everyone's way. And at other times when there is nothing to do, I think pulling out a phone in a patient care area is just using time efficiently.
ReplyDeleteLooking ahead to beginning clinical rotations in July, I just want to remind everyone to just communicate your expectations! … After two years of shadowing in which we are literally told (in some settings) to NEVER TOUCH A PATIENT it can be pretty easy to not know your place. If this was an audition-type rotation that's obviously not the case anymore. But in general, do remember we med students are in a new environment ever six weeks (and very often every two weeks in schools like mine, with multiple locations for a given clerkship). So just be nice and say, "Hey, could you jump in here, we expect students to help with this unless they've been asked to do something else." … Also, for med students - you need to communicate too. I know some people in the generation ahead of me are weird about cell phones. When I am shadowing I try to be really explicit about the fact that I have some databases I search on my phone and that I sometimes record new terms or presentations (no patient details whatsoever, but like "erythema nodosum associated with strep - look it up." … I make sure the doc I am working with is okay with this and I don't do it in front of patients unless I say, "Would you like me to look that up for you?" and take out my phone ...
ReplyDeleteAgree that it is best to note that you're looking up something relevant when you're in the presence of an attending/resident or a patient. During residency I often saw students texting or surfing Facebook in the presence of attending physicians, which struck me as odd because my classmates and I never did that during rotations. I did call them out on it -- phone only for medical purposes or urgent matters and best to find a non-annoying way to convey your purpose. I do think it's nice to read articles and educational resources on the phone during team downtime. Once your team knows your style, assuming you're a hard worker and engaged team member, you probably don't need to announce your task.
DeleteEven if your superiors are aware that you're using the phone for good, patients don't know that and will feel disrespected -- if I use the phone for anything in front of a patient I am very clear about the reason and never use for anything that is not either related to their case or, in very rare cases, urgent.
I think some people here are being far too forgiving. It's one thing to be texting in the OR when, say, observing, unscrubbed, when nothing is going on. But when the patient is being transferred? On an audition rotation by a student who, presumably, has been in the OR before? Anyhow, no one is entitled to a reference.
ReplyDeleteI'll also say that - as a resident - I've observed more than a few students display complete obliviousness to professional behaviour. I can recall one student on an elective who left a discharge summary unfinished to go to lunch. It wasn't even half done. Her clinical skills and knowledge were well below expectations too, but it's not acceptable to peace out for lunch and (in this case) leave someone else to finish the work.
I don't think it's ok for a student to text in the OR. Even if a student thinks nothing is happening it's part of his/her job to be fully present and vigilant for ways in which s/he might either be helpful or in some cases get out of the way. Students who text in the OR or during clinical rotations will not get a good eval from most of their residents or attendings. Save the social texting for breaks and if you have to coordinate a meeting with other students then at least let folks know that you have a legitimate purpose.
DeleteAwfully happy not to be a medical student any more, although, for the record, my dressings stayed on, by golly. Smart phones weren't invented then. Of course, the difference between medical student and dog poop is that nobody goes out their way to step on dog poop. Sounds like things haven't changed much.
ReplyDelete'
I am a paramedic, but back when I was a student the iphone was not around, so it was only geeks (or people married to geeks like me) who had smart phones.
ReplyDeleteThe no personal phones to be seen was pretty big then, but one day we got a problem patient who couldn't communicate with us, but had some unusual medication that was going to help us figure out what was wrong with them. I indicated to my supervisor I was going to use the smart phone to look up the medication (it turned out to be VERY good that we did).
Even management now are recognizing that smart phones can be useful in health. And I like that I can quickly look up something mentioned rather than trying to remember it for later.
I do agree with what others are saying though about clearly communicating your expectations to students though! I am also a nurse, and I hate seeing the poor med student chewed out for not doing something the way DrB wants done, when yesterday DrA chewed them out and made them do it that way the day before.
Geeze. Maybe next time I text a colleague on rounds about a consult that the team need them to see I'll think twice.
ReplyDeleteDon't think twice -- just mention something like, "Oh, I can text him now to give him a heads up so he might see our patient sooner."
Delete1. How do we know the student was actually texting (compared to the gazillion other things one can do on a phone)? Did the student announce it or was there a screenshot?
ReplyDelete2. If he was on an audition rotation, it may be a different hospital - and different rules. In some places I've been the med student had better not touch the patient during transfer or the nurses will be furious. In my home institution, the student had better grab the feet. At a different away, it was the resident, student and anesthesiologist who moved the patient - nurses were too important for that. Different strokes for different folks.
3. Who took the picture and who forwarded it to the attending? Seriously throwing the student under the bus. I mean, if the whole rotation sucked that's one thing; but if it were an isolated incident? In that case, not cool and the med student really escaped.
~Jasmine
4th year med student here. Tthere's a good chance he was rotating during interview season. I know I missed opportunities to interview because I was in the OR and was unable to respond or schedule an interview as soon as one was offered. Some of the older docs don't realize that you need to be on that phone damn near every 10 minutes during business hours when interviews are being offered because of how competitive residency is becoming. There are valid reasons to be on the phone.
ReplyDeleteSo, what can we say in defense of this attending?
ReplyDeleteWell, we can say that as long as the system in which he works is competitive as asks him to grade students according to their subjective qualities of character, he is going to have to do that. If a letter means anything, it means that.
What is wrong with what the attending did?
He was unprofessional, and in a much more serious way than briefly having your phone out in the OR.
First, it seems as though he didn't seek any more information about what had happened, didn't talk to the student about what they were doing, just held on to the photograph until it was time to shock and embarrass the student when they predictably asked for a letter.
That is horrible teaching. You say something in the moment, or you pull the person aside after.
Second, he's gloating about his power over this student and how easily and thoroughly he smashed their hopes. That's pathetic. If professionalism in physicians means anything, it means that we, the attending physicians, have a responsibility to residents, students, and other learners, to support and encourage their professional development. Who does a "gotcha" on a medical student, really? They know NOTHING. They are learning how we expect them to behave. They are learning medicine. They have NO power in the system. They screw up, you gently correct them. Lathe, rinse, repeat. And repeat.
If they screw up a lot, or fail to improve, they don't get a letter. But that's no excuse to sneer or be smug at their failure, which is also, since you are their teacher, your failure as well.
Unfortunately an important piece of the story is missing: was it a personal text or work related? However, your thoughtful response: "You say something in the moment, or you pull the person aside after" gave me pause for thought. In a world filled with social media sites, it's easy to make assumptions . I, for one, am guilty. My bad. As you correctly stated: "They have NO power in the system" , and lastly, "If they screw up a lot, or fail to improve, they don't get a letter," but you don't abuse your power
Deletesimply because it's available to you. As my father in-law, who was in law enforcement, once said to me about carrying a gun, "it humbles me."
Yes, words to live by.
- Paul
- Paul