Clinical Guide The Nerd's Guide to Pre-Rounding Table of Contents Part 9. Making the Grade: Emotional Intelligence Trumps All Clerkships begin the onset of formal grades for UCSF med students. Many of us, reverting to lifelong habit, focus our anxieties in terms of getting good evaluations, which are seen as the key to reaching career goals. While a solid fund of knowledge is usually the first item on the evaluation scorecard, I maintain that emotional intelligence may ultimately play an equal or greater part in your evaluations as your strict competence or knowledge. Some students may be completely oblivious to this reality, to their peril. By "emotional intelligence" I mean things like your adaptability, maturity, sense of humor, professionalism, and ability to get along with others. Such factors are also part of your "scorecard"—however, they have a stronger global influence on your evaluators than other single characteristics. Take, for example, my comments about carrying a peripheral brain. Although I’m not a slouch in the fund of knowledge department, I am usually pretty spazzy when pimped, and often come off a little clueless. However, the fact that I carried a peripheral brain showed a professionalism that prejudiced my superiors in my favor. As a result, I think they often "up-graded" my "fund-of-knowledge" score, despite the fact that my knowledge base may have been pretty average. This is an example of how professionalism can positively impact other characteristics of your performance. The comments below are intended to help you be ready for the environment of the wards and clinics, so that you can demonstrate professionalism even under duress. They are also intended to give you a gut sense of what sorts of demeanors, attitudes, or behaviors come off well on the wards. The Horrible Truth About the Wards. They are very different from the "kinder, gentler" environment of the medical school. Many students are mildly traumatized when they witness, or receive, grossly rude or disrespectful behavior on the part of their superior officers. The humane and respectful treatment we students receive in the first two years at UCSF Med contrasts sharply with the too-often toxic and disrespectful treatment on the wards. How to deal with this? I recommend, first of all, that you prepare ahead of time for such conditions, so that you are not surprised when you see/experience beastly behavior. A little ego trouncing is de rigeur for students on the wards. In fact, your ego on the wards is like carry-on luggage on a plane trip: If it’s too big, it’s going to get smooshed. You’re better off not carrying it with you. I think it would also be a good idea to remember how it feels to be treated that way, so that you will not perpetuate such toxicity when you (in short order) ascend the ranks of power. Personally, I’m baffled as to why behavior that would never be tolerated in any other work environment, is simply ignored in our own profession. Only our collective resolve to eliminate such behavior, or at least not perpetuate it, will improve conditions for those coming in our wake. A sense of humor is crucial. It’s also important not to take such treatment personally—usually it has nothing to do with you, and virtually any medical student in your shoes would be receiving the same treatment. Talking over experiences with your classmates, and venting, are also great releases. And if you wind up in a bathroom stall crying, that does not make you a loser. You are in very good company—you’d be surprised at how many of us have literally been in that place. It is a healthy sign that you are a human being, with feelings. Allow yourself the right to feel hurt. And remember the problem is with a medical culture that tolerates such unprofessional behavior, not with you.[17] On the other hand, here’s a weird idea: it’s called "Empathizing Up." As students, we’re often encouraged to put ourselves in the place of our patients and empathize with their needs. Since Western medicine is traditionally hierarchical,[18] with patients on the "bottom rung," I call this "empathizing down." However, we’re rarely instructed to put ourselves in the role of our superiors. Yet our residents and attendings may be suffering almost as much, emotionally, as our patients. They are over-worked, underpaid, exhausted, and often don’t see their loved ones for days at a time. They may have lost marriages, relationships, and other cherished parts of their lives to their careers. None of this is an excuse for bad behavior, but when someone behaves toxically on the wards or clinics, keep in mind that they probably are not malicious—they’re just thoughtless. They may just be having a bad day. (Or a bad life!) Their bad behavior is an outgrowth of their suffering. If you keep that in mind, you may forget about how bad you felt being on the receiving end of their cattle prod, and instead develop compassion for someone in a bad place—or at least a resolution not to repeat their example. When working with "toxic" personalities, I try to focus on some good characteristic of the person. I assume everyone I work with on the wards has something to teach me. And often this helps me find ways of working with them. That grouchy resident may be an excellent team leader. Or, as one of my peers commented, "Dr. Jones did make me cry when I presented to him—but he also coached me and taught me how to make a good presentation." Also, don’t be too quick to label someone as a "bad guy." If your intern is post-call the first time you meet her, she may not be the person she usually is with the team. So don’t rush to judge. I found it usually took a week for me to a get a measure of a person. Being able to "bounce back" from bad treatment with humor and maturity will always help you. In fact, at times it may make a crucial difference in your evaluations. So, aim for it. Also: While you may need to tolerate some "rough treatment," you should never put up with treatment you consider abusive—esp. if you feel sexually harassed, or if you feel personally attacked. If such a situation arises, it is professional, and responsible, to report it to your program director. Vitamin C or "You Shall Fear Neither Rhino Nor Tiger." If I could give one piece of advice on how to do well on the wards, this is it: Conduct yourself at all times with cheerful confidence. That’s it. People who always seem confident always do well on the wards, even if they have only so-so funds of knowledge and patient skills. Ask any fourth year, and they’ll confirm this. It’s startling. By the way, some people confuse "projecting confidence" with "having a big ego." This is incorrect. It is possible to outwardly seem confident while inwardly feeling unsure. It is your demeanor that is important. Think about the old campaign from Arid Anti-Perspirant: "Never let ’em see you sweat." Now I, unfortunately, was not someone who could pretend to feel confident, or cheerful, when I had utterly no idea what was going on and was worried sick about looking stupid. I often came off as pretty spazzy, in fact. For me, the way to seem confident, was to be confident—which is why I have all these suggestions for being prepared. If you are one of those gifted beings that simply has savoir faire, knows what to do, seems at perfect ease and will take to the wards like a duck to water, well then: Bully for you! This guide, however, is for the rest of us. Punctuality. An easy way to look professional. It’s important. ’Nuf sed. . Spin Control: A Balm for When You Bomb. You will have days when you screw up. Sometimes, only you will notice; other times, you will be made explicitly aware that your teammates have noticed as well. We all want to do well on the wards. It’s possible that, for some of us, even a slight screw up will make us feel like utter failures. It’s important to keep a sense of humor and keep things in perspective. Below are a few "war stories" that you can think about the next time you feel like a complete bonehead: When I was on my medicine clerkship, the program director would have the medical students tour around to each others’ patients and demonstrate interesting physical findings. Now, as if I weren’t nervous enough about my exam skills, every time I laid hands on a patient, my program director would tell me I was doing the exam wrong. EVERY TIME. Cardiac auscultation, spleen palpation, lung percussion: You name it, I did it wrong. I was sure, since all my evaluations went through this guy, that I was doomed to get a lousy score. The fact that I wanted to go into internal medicine only made me feel worse. Guess what? I got honors on that rotation. Another story: During one of my rotations, I overslept several times during call, arriving late to pre-rounds and often not being able to do even a minimal job of collecting data on my patient. One morning, one of my senior residents approached me afterwards, shook her finger in my face, and growled: "I have a bone to pick with you." She then let me know that pre-rounding in 2 minutes was NOT acceptable performance. At the time, I wished the ground would open and swallow me. She was right; I felt terrible. The fact that this had happened more than once made me feel even worse. "Well, I guess I can kiss honors on this rotation good-bye," I thought to myself. Guess what? I got honors on that rotation, too. And I’m on very friendly terms with that resident. A final story: During a stint in the clinics, I assessed a lady with the chief complaint of vertigo. When I presented to my attending, I told him I suspected she was having a stroke. After seeing the patient with me, he came up with a simpler explanation for her dizziness: An ear infection. (All together now: Oooof!) Boy, did I feel stupid. And yet, only 20 minutes later, that same attending gave me my end-of-rotation feedback: He was recommending me for honors. The point of the above stories is to remind you that one, or a few, mistakes, no matter how excruciating they may feel to you, do not necessarily determine your entire clerkship grade. Your grades are a reflection of total effort over 6 weeks under many different evaluators. So don’t get overly discouraged by your screw ups. In fact, I would advise, based on the experiences of others, that you be careful not to let your reaction to a mistake lead to so much anxiety that you overcompensate. One friend was so eager to demonstrate excellent fund of knowledge, in the face of early feedback that his fund was not so good, that he became, in his own judgement, "too pushy" to show his knowledge. This rubbed his teammates the wrong way, leading—as most such "emotional intelligence" factors do—to a global effect on his evaluation. In this case, negative. At some point after an error (during a break, at home, in the shower…), pause, take a breath, and think about how you will do things differently from now on to avoid repeating the mistake. It sucks to screw up, but it sucks worse if you don’t improve from your mistakes. So analyze them. Gunners: the Demon Within. What’s a gunner? Some people define it as: "An ambitious person focused on getting a great evaluation." I do not think that’s a gunner; I think that describes most of us in medical school. I would define a gunner as "an ambitious person focused on getting a great evaluation… to the detriment of others, including his patients or his peers." Many of my classmates have complained to me of "gunner" behavior by peers on the wards that they found annoying, disturbing, aggravating, and unfair. And I think it’s true that when we think of the "problem" of "gunning," we usually think of it in terms of other people’s behavior. I would suggest, however, that the problem of "gunning" begins at home. In other words: Beware the Gunner Within. How to do this? It’s inevitable, after about the first week of clerkships, that you will notice that some of your peers are going to be doing excellent work. And, in the new era of being evaluated, one’s conditioning might lead one to feeling insecure, and even jealous, of that person’s good standing with the team. If you notice yourself developing such feelings about a classmate, stop yourself. Instead of indulging your Inner Child’s whining, "Why don’t they give gold stars to ME?", ask yourself, "What is this person doing that I can emulate?" If you have a peer who seems to have what it takes to perform well on the wards, STUDY THEM. They’ve obviously figured out what works. To indulge the jealous or competitive impulse, on the other hand, leads to very bad behavior—even if we’re not the ones perpetrating it. As one example, on one of my clerkships, I noticed that one of my peers got into the habit of correcting things I said in front of my residents. Now, sometimes he was right, but I noticed that he was also doing it even when he was incorrect. Apparently he thought correcting my "errors" (even when I didn’t make any) made him look smarter. And my confidence was so shaken, I actually started to believe he was right about things, even when he got it wrong. When it reached that point, I resolved to speak to him in private about it, gently draw his attention to what he was doing (since I was sure (wink-wink) that he wasn’t doing this on purpose), and ask him not to do it. As a general guideline for all medical students, might I suggest the following: Show your peers the courtesy of never correcting them in front of their evaluators, unless it poses an immediate health risk to a patient. You can gently correct them behind the scenes, if you must. If a public correction is needed, let it be done by the resident or attending—not by you. Many students complain about peer behaviors that are not exactly wrong, but seem phony or unfair, such as kissing up, making small talk with attendings about their personal interests, using personal connections to socialize with superiors outside of the wards, or even flirting with superiors. Students complain that people engaging in such behaviors may have crummy patient skills or lousy funds of knowledge, but thanks to such "butt kissing" they are still able to do well. Let’s use some of the advice from above to dissect these complaints. First of all, your concern should be with your own conduct and performance. If you’re doing an excellent job, what they do shouldn’t matter as much. As far as such behavior giving an unfair advantage, I agree flirting is simply unethical, and I would not engage in it. As for using personal connections, that’s something you either have, or you don’t. Some people are born looking like movie stars, and the rest of us aren’t, and that doesn’t seem fair either, but that’s life. In the long run, relying on such behaviors to advance is a crutch that weakens a person’s reliance on their own internal resources. Destined for eventual trouble. Not recommended. But what about "butt-kissing"? Here’s a weird idea: What if some of those behaviors were not seen as "butt-kissing," but rather as a form of "schmoozing," or professional networking? Rather than sullenly focusing our jealousy at the unfair advantage such behaviors give our "competitors," consider whether such behaviors are actually genuinely friendly and an attempt to make a connection with someone. In other words, maybe your peer is exhibiting a form of "emotional intelligence" in strengthening their rapport with a member of the team. Their ability to do this may be unique to them, but it might also be a skill you can study and learn from. While I don’t suggest you do anything that would feel "phony" or "fake" or "cheesy," I think you should consider finding ways in which you, too, might make a personal connection with teammates. Perhaps part of why "butt-kissing" bothers us is that we feel the butt-kissers do it so they can slack off on other parts of their work and still get a good evaluation. In other words, we suspect they’re lazy. We might also feel that these people are only looking out for their own well-being, and not for their patients or anyone else. In other words, they’re "gunners," in my use of the word. We don’t have any control over other people’s motivations. But I would say, if your heart and motivation are in the right place, there’s no harm in borrowing the tactics of the "butt-kissers" to accomplish your own, hopefully more meritable, goals. [17] Why do students elicit such treatment? A quick analysis: Most doctors tend to be perfectionist control freaks, and many of them are secretly insecure. Seeing students stumble reminds them of their own, personal development as doctors, and of their own shortfalls. The way they treat their juniors, esp. students, is a projection of their own neurotic insecurity and self-denigration. [Back] [18] Not that I endorse this. [Back]