Phenomenal Food and Phenomenal Doctors

October 01, 2017

Hi everyone:

We use the adjective “phenomenal” too loosely.  For example, Heide says I’m pleased too easily and therefore too quick to call food phenomenal.  Her standards are higher, and I see her point when we visit truly incredible restaurants like Le Petit Café in Branford or La Zingara in Bethel.  Heide’s cooking is phenomenal too.

What makes a master chef great?  For one thing, masters always cook their dishes perfectly and serve them at the right temperature. They season with finesse, balancing salt, fat, acid, and heat.  Their meals are visually appealing and variably textured.  They surprise us with innovative ingredients and they create flavors and aromas that make our hearts pound.  They leave us speechless.  Bad experiences aside, consider your last meal.  Were you happy or were you euphoric?  Good food is common, but phenomenal meals are rare.

What makes a physician phenomenal?  I think I know some of the ingredients: deep intelligence, wells of knowledge, selfless dedication to patients and colleagues, and a never ending commitment to self-improvement.  Great physicians hear nuance.  They communicate clearly and choose their words carefully. They are honest, modest, and trustworthy.  They collaborate.  They provide the same outstanding care to all patients, even if they can’t pay, and even if their illnesses resulted from regrettable habits.  Phenomenal physicians use their position in society to promote equity and social justice.  They seek out knowledge and share what they learn with colleagues and students.  They practice their craft with religious fervor.  None of the great physicians I know think they’re phenomenal, but they all aspire to be.  A phenomenal physician is the kind I’d choose for my family, or myself.

As with food, we can too easily conflate good physicians with great ones and only realize the difference when we witness truly inspired work.  Fortunately, phenomenal physicians surround us at Yale, and each of our residents has the potential to become phenomenal too.  What skills do you need to wear the badge?

I’ll close with some wonderful ideas shared with me over the last week by housestaff and faculty.  Look them over.  Which ones speak to you?  Where can you grow?  Let’s be phenomenal together.

And now off to the MICU,

Mark


From an attending:

Resident:

  • Knows medicine
  • Simultaneously confident and earnest
  • Owns the role of team leader
  • Able to assess, understand, and meet learners where they are
  • Able to model skills and behaviors such as patient-centered interviewing, bedside physical examination, clinical reasoning, patient advocacy
  • Interested in and passionate about patients, teaching/learning
  • Understands common biases and cognitive traps, with strategies to assess and avoid

Intern:

  • Understands and respects the profound responsibility we have as physicians
  • Able to amass, assess, and interpret information from varied sources to formulate a patient-centered treatment plan
  • Knows the limits of their skills, knowledge, and experience, and as such knows when to ask for assistance
  • Able to demonstrate empathy at the bedside regardless of how many days they've worked or the hour of the day

 

From an intern:

Drawing from my collective experience after two months at Yale, some of the most phenomenal residents I've had:

  • always seem to have the patience to let me explore autonomy when comfortable and safe
  • challenge me to rise above my previous standards and push my clinical knowledge/problem solving skills (I personally enjoy it when residents ask me what I would do or challenge a clinical decision I've made)
  • are upfront about goal setting, and frequently check in or provide feedback
  • keep resident wellness in mind and are keen to divide workloads appropriately, share in patient tasks
  • share some quick topic presentations or teaching relevant to their interests

 

From an intern:

When I think of this question, three people immediately come to mind…

[One resident] displays several characteristics that I believe makes her a truly exceptional resident; these are as follows. Not only does she manage patient care from a birds eye view, ensuring that larger disposition and long-term goals are addressed, but also has a strong handle of the details necessary in each patient to ensure the intern does not miss anything. She allows for intern autonomy as appropriate, considering intern confidence/ability level. She remains level headed in the face of several admissions at once, and is able to break down complex patients to key issues to prioritize the safety of the patient. I also appreciated her constructive feedback and debriefing sessions--early on, I discussed with her what I wanted to work on during the rotation, and she gave me specific, constructive, helpful advice that completely changed my workflow. She also prioritizes medical/intern/resident education--we never missed a single noon conference with her, even on the busiest of admitting days. More than anything, she is incredibly kind, and is able to make the most grueling work days positive, fun, and educational due to her spirit. What makes [this resident] even more special is her ability to identify when interns are struggling, and to address this is a nonjudgmental, supportive way, to ensure that the intern never feels overwhelmed (this was the case for both me but my co-intern as well). After a tough, long, admitting day that I was feeling particularly down, she stayed an extra thirty minutes talking to me about how I was feeling, what were barriers to having a more efficient work day, and how to address these.

[Another resident] is also a phenomenal resident in my opinion, for many reasons, but in particular due to the fact that he is an outstanding educator. When I was on nights with him, he took every possibility to teach me and to prioritize my learning, whatever topic I wished. He has a strong knowledge base, and if I wanted to learn about something he was not familiar with, he would look up the topic to help me. He also walked me through how he approached MKSAP questions. Probably the most helpful aspect of his performance was his willingness to sit down and thoroughly review every H&P I wrote, and would give feedback to me on my presentations every day, to ensure that early on in my career I understood these core principles of communication to the medical team. I feel like this set a very strong foundation for me for the next three years and beyond. He always remained positive and calm, and created a very open working environment.

-Last but certainly not least, I believe [another resident] is a phenomenal resident due to the fact that he is a productive, invaluable citizen of the residency program. Whenever he sees a problem, he chooses to find a way to fix it rather than let it linger--whether it is suggesting improvements the CCU schedule for residents, or creating better mechanisms for feedback, or serving on several committees. I also worked with him in the CCU and found it hard to believe he was only a second year--he has the maturity and confidence to handle problems with confidence and diligence, which carries over in to how he addresses larger issues he sees with the program. 

Phenomenal interns that come to mind are…

[One intern] has more dedication to learning his craft and providing the best possible care to his patient than any other intern I have seen. Despite having a busy schedule, he manages to continue to read and educate himself while juggling his daily tasks efficiently and seemingly at ease…An example of this was on CCU nights, when not only would he have prepared teaching points on the patients he had admitted overnight, but if there was extra time, he would read about other patients on our sign out and have suggestions for updates/changes in management based on evidence he had read overnight. He is also a wonderful patient advocate, and he even came in to PCC on his vacation day to ensure that paperwork he was not able to address earlier during his block was complete. He is kind, loyal, and is always willing to offer his co-interns and residents a helping hand.

[Two interns] both really impress me in their independence as beginning of the year interns, not afraid to make major decisions in patient care that they felt comfortable they could handle, yet still knowing when to call help. In particular, on [their busy overnight team], they were able to manage very sick patients who ended up being transferred to the MICU with little assistance, knew how to stabilize the patients and while calling the MICU attending, and were not thrown by the challenge.


From a resident:

One resident- Coming into the hospital after clinic last year in order to spend time and talk with and translate for a [patient who didn’t speak English] (who was not anyone he knew personally) hospitalized at YNHH

One preliminary intern- Consistently went back to patients' rooms in the afternoons/ evenings not only to update them but also just to spend time with and get to know them as people evenings after his work was done.

One resident- Created a thoughtful and fun gift for Yogesh by spending hours drawing Yogesh in cartoon form and publishing his artwork on the billboard on the way to the West Haven VA

Recent graduates- Came over to Fitkin in the middle of the night in order to help me with an LP despite having their own patients to admit/ work to do

One resident- Staying late on several occasions after…day shifts in order to ensure that transitions of care went smoothly and safety for several ill patients who had to be transferred to the SDU/ MICU

One resident- Bringing one of his new clinic patients with recently diagnosed cancer to the oncology clinic immediately after their primary care visit with him in order to ensure a smooth transition of care and that the patient was seen in a timely manner

 

From an intern:

At baseline: every resident I've worked with has a fantastic clinical knowledge base

Above & beyond: "tuning in", meaning - am I busy getting through notes? Leave me to it. Am I under some pressure but still managing and keeping my head above water? Frequent check-ins. Or (and this is where it matters the most to me) am I clearly fried, panicked, cannot humanly get all of these tasks done in the next hour, and I am directly communicating to you that I truly, truly need help? Rolling up their sleeves & diving in without hesitation or judgment with debriefing later. In sum, active effort in synching with my cues and my workflow (as I try to do with theirs) to most efficiently handle tasks in a changing day. It's not so much hovering, more like just paying attention. Without that feeling of cohesive support, it's tough to even think about learning, which is the whole point of why I'm here. 

that's the kind of resident I want to be like next year :)

 

From an attending:

Intern: "know thy patient"... as much as info is easily accessible, there is nothing more reassuring than an intern who just remembers that creatinine bump last week or baseline Hb without thumbs in super swipe mode or "MrX really not a morning person, let's leave him for the end of rounds"

Resident: "head on a swivel", aware of everything going on, proactively making things happen, basically the attending feels obsolete and is forced to come up with out of usual teaching routine  Colleague: An attending brought her blender from home for a preliver Txp patient with severe CDiff  to get a fecal transplant (they really broke the mold when they made her...)

 

From a resident:

Perhaps the trait I valued most in my residents was flexibility.  They would either discuss with me or just seem to know where I was struggling / what I needed help with (be it in terms of knowledge, day to day tasks) etc and would step in to pick up the slack.  There were no resident tasks or intern tasks (well, okay, maybe care coordination rounds, note writing, holding pager, etc), but they were there to protect my time and maximize my learning.

My favorite interns so far have been earnest: eager to learn, eager to work, engaged with what they are doing, excited.  Thoroughness definitely helps.  In the words of a med school mentor of mine: the key to success as a clinician is three-fold: be compulsive, be compulsive, and be compulsive. 


From a resident:

1. Resident: Team player; exceptional communicator; able to assess the strengths, weaknesses, and needs of all team members and adjusts own approach accordingly; puts their own pride aside and acts foremost to the benefit of the patient and the team (especially the intern); leads with intent to provide an example to trainees; teaches frequently and ALWAYS makes a point of acknowledging the limits of their own knowledge and understanding; accepts others input and opinions and is able to turn any disagreement into an opportunity for mutual growth and learning; NEVER thinks of or acts towards their peers in a way that is demeaning or belittling.

2. Intern: proactive; responsive to feedback and constructive criticism; curious; takes ownership over patients and advocates for what they think is best; aware of their own limitations; constantly asking questions to gain a deeper understanding of what is going on around them; organized; timely; honest

 

From a resident:

I would say for both Interns and Residents having a high ability to read other people whether that is fellow team members or patients. 

For interns specifically there obviously needs to be certain attention to detail, but also a questioning attitude and not being afraid to question one's senior or attending if one thinks the more senior team member is making a decisions based off of incorrect or out of date information-- in the process everyone can learn something and false information/knowledge will not be propagated. 

For resident, having a high situational awareness is quite helpful, being aware when one's intern is overwhelmed or needs assistance/emotional support but might not be able to express it or ask for help. As a resident one also must be honest with one's self about what one knows and what was does not, not be afraid to look things quite expeditiously and effectively filter and teach information to the team 


From an attending

Same for both interns and residents: Respect for their position in society and in the healthcare team, and an understanding of the importance of the inter-personal relationship.

 

From an attending

  • A commitment to reviewing the chart (old notes, history), empathy, a practice of self-reflection
  • can-do attitude, efficiency, awareness of one’s limitations

 

From an attending

Resident: calm, in control, humble, organized, unruffled, team player, supportive, unafraid to do work normally designated for interns, can-do attitude, respects all staff and team members

Interns: eager, enthusiastic, organized, able to take direction without getting defensive, treats all staff with respect, unafraid to ask questions and to ask for help, puts patients first, does not take self too seriously (otherwise it's a long year!)

 

From an attending

What makes a resident phenomenal? ABILITY TO DEMONSTRATE LEADERSHIP, ORGANIZE A TEAM, HELP PRIORITIZE WHAT IS MOST IMPORTANT FOR AN INTERN, CREATE A GREAT LEARNING CLIMATE FOR STUDENTS AND INTERNS, ABILITY TO BE A TEAM PLAYER WITH CO-RESIDENTS, ROLE MODEL EACH OF THE QUALITIES OUTLINED BELOW

What makes an intern phenomenal? OUTSTANDING FUND OF KNOWLEDGE, ABILITY TO ACCEPT AND RESPOND TO FEEDBACK RAPIDLY (CHANGES IN PRESENTATIONS FROM ONE DAY TO THE NEXT BASED ON FEEDBACK), GREAT BEDSIDE MANNER WHICH IS EVIDENT FROM THE WAY A PATIENT RESPONDS TO THE INTERN, ABILITY TO PRIORITIZE AND ORGANIZE, EFFICIENCY


From a resident:

A great resident can effectively micro manage without ever becoming a burdensome presence. We all perform better when we do not feel that our work is being scrutinized at every step. It is impossible to learn when we are not allowed any ownership of our work.  For this reason, the best residents I've seen are those who manage a team without the intern ever getting the impression that they are not the one in control. 

Great interns above all else are skilled communicators.  If the job of being an intern is distilled to a single task it is synthesizing data into a format that can be conveyed to your patient, resident, attending, and various other team members. Skilled communication means being a presence at the bedside, presenting confidently from memory, and writing succinct but thorough notes.

Submitted by Mark David Siegel on October 02, 2017