“The worst enemy of a doctor is another doctor,” said one of my professors during rounds when I was doing my internal medicine clerkship as a third-year medical student. I remained skeptical. That did not match the idea of becoming a doctor nor did it support what Dr. Pellegrini said: “Medicine is the most humane of the sciences.” Nonetheless, my old professor explained that when it comes to patient care planning and medical education, moderated discussion and positive feedback is what facilitates progress. It’s not a deleterious fight of egos like when highly competitive colleagues are in place and want to show superiority — more than often lacking what they claim to have — as if they were begging for admiration. Many of you might disagree with the previous paragraph based on the argument that diversity of opinions and perspectives is a fundamental part in academic medicine and training of future doctors providing countless benefits to patient care, as well as it is the starting point for improvement as in any other field beside medicine. Sometimes, however, diversity of ideas can turn into a chain of negative thoughts that may result detrimental for other persons. Although I have no scientific evidence to support this and, contrary to what we are taught to believe in a fact-driven culture, common sense and empiric observations have turned out to be more than enough evidence that resulted in significant findings. John Snow and his empirical observations on a water street pump led to the end of the cholera epidemic in London in 1854 and is one clear example of this. Furthermore, it’s from an empiric knowledge that the scientific method we know and apply today was formulated many years ago and since then has changed many aspects of human life. All of that, again, started with simple observations like the one I’ll share from my short experience as an internal medicine intern in a community hospital in New York. The first one comes from a conversation I had with one of my co-interns, and also a good friend of mine, after the end of the first rotation. I asked how was she doing. It was not a generic question you ask every day, but I really meant to know if she was doing well as I had noted her to be in a clearly different mood as the way I know she is from the orientation weeks before starting residency. Not surprisingly, she told me she was feeling “like crap” after reviewing the evaluation from her senior resident for that floor rotation. Diana, just to say a fictitious name, logged in to her new innovation account to show me: “lacks the character that is needed to be a doctor,” “will not be a good doctor,” and “does not know how to act during stress situations” were among those lines. Needless to say that after reading that, I knew exactly why she was feeling like that and also why she was lacking the motivation and enthusiasm the following months. T.I., another intern doing her preliminary year before going into radiology at a different hospital, is part of my second observation that took place during the ICU rotation. She’s the introvert and shy type of person that doesn’t usually talk too much by her own initiative but that, after couple of questions, her face would flush and she would open herself up and spend hours talking about any topic. Unfortunately, she struggled to find the proper words and the right sequence of events during the sign out to the morning team despite spending a reasonable amount of time reviewing and trying to take note of any single detail of our critically-ill patients. Two or three sentences after starting her first patient presentation, day after day, she would be dismissed by one of our senior residents without warning, leaving an already struggling resident with no opportunity to participate in an activity that, in fact, was assigned to us interns as mandatory with the purpose of improving our presentation skills by being overseen and supported by senior residents. Instead, she likely encountered the worst two enemies of her internship: being ignored and feeling helpless. No reassuring words or attempts to help sufficed. And, as a consequence, she completed her only and last ICU rotation of her life without mastering something that she was supposed to be taught. The third and last observation derives from a face-to-face end-of-rotation evaluation I had with one of the floor attendings. He asked me questions on topics and patients encountered during that month. After several questions, he provided clear and constructive feedback in a very professional way. Overall, the attending had showed himself satisfied with my performance and politely reported feeling surprised as he had received negative critics about me from other attendings prior to my rotation. His words caught me by surprise. I wasn’t expecting any compliment, but I was not anticipating that since I had received nothing but satisfactory end-of-rotation evaluations — both person-to-person and electronically — from eight different attendings from the prior rotations. According to the ACGME in the United States, program directors and trainees must fill out and receive evaluations and feedback on regular basis with aims to improve resident education. By doing so, participants comply with the requirements that were meant to assure — at least on the records — that trainees meet certain milestones to optimally perform as future independent physicians. Many, if not all, programs submit these by electronic means and it is reasonable for programs to do it face-to-face, however many times and similar to the situation with electronic health records (EHR), documented information does not match real-life encounters as exemplified in the aforementioned paragraphs. Unfortunately, the result of this information mismatch is unfulfillment of professionalism milestone (one of such ACGME requirements, by the way) by the two parts and suffering of patient care by giving conflicting and unconstructive feedback during the most critical stage of a physician’s training. Hypocrisy, a common denominator found in my observations and what reminded me from my old professor’s saying, is a harmful and deleterious practice. Diversity of ideas should not result in conflict. Residency by itself is already challenging enough emotionally, physically and intellectually. And by adding unnecessary burden, not only our ethics and principles are violated but the entire health care system suffers the consequences of forming an already burned-out generation of physicians wary to meet the demands of our complex system. Optimal feedback, I suggest, should be frequent, timely, and specific. It should be delivered in a honest but yet professional way so that receivers are provided the tools necessary to take advantage of it and use it in their best interest that will benefit patients as a result. We should make use of the available tool and technologies to our advantage and for the benefit of our patients. We should not settle with documentation of misleading information, instead we should be able to recognize where trainees are failing at and to point it out clearly so that trainees can put all their effort to it and change for the best. To my dear fellow senior colleagues, who rely on the responsibility of forming the future generation of physicians — I encourage you to strive for excellence in your commitment with your mission of being a doctor that includes compromise with medical education. Remind yourself that residency is a training stage and as such, trainees are supposed to learn and be taught. We, residents, need guidance more than ever as someday soon we will be out taking care of our own patients. That’s where residency differs more from medical school. Remember today’s clinical practice is considerably different from decades ago and it’ll continue to change and become more demanding with the goal to provide the highest quality care possible to our patients and requires compromise from both ends to achieve this. There’s no doubt that receiving proper feedback is critical during this stage of physician training and that it’ll provide the tools needed to meet those demands. We should not settle for less, because if we do so we would be failing to fulfill our purpose of being advocates for and improve the well-being of our patients. Lastly, I’m aware that my observations are only few and minor examples among the wide spectrum of unfortunate and unanticipated experiences encountered during residency (notably different for those in surgical specialties). And I do not pretend to be exhaustive, nor to be compared with great physicians like John Snow by any means, but to raise awareness and remind everybody in this great profession regardless of the field that, contrary to what my old medicine professor once said, the worst enemy of a doctor should never be another doctor. Edgardo Olvera Lopez is an internal medicine physician. Source
