Types of residents

Posted on: 2018-11-22 07:53:18

Michelle M. Kittleson, MD, PhD, is Director of Education in Heart Failure and Transplantation and Director of Heart Failure Research, Department of Cardiology, Cedars-Sinai Heart Institute.

Corresponding author: Michelle M. Kittleson, MD, PhD, Cedars-Sinai Heart Institute, Department of Cardiology, 8536 Wilshire Boulevard, Suite 301, Los Angeles, CA 90211, 310.248.8300, fax 310.248.8333, michelle.kittleson@cshs.org

My parents taught me that pride in a job well done should be reward enough. As Indian immigrants, they were tiger parentsbefore the term was ever coined. An "A" on a test wasn't good enough, unless it was the highest score in the class. We had exhaustive discussions about who the smartest kid in class was, and what made him or her so successful. I somehow soldiered on under the crushing weight of their expectations, and perhaps because of this, the pressure of medical school and residency and fellowship did not feel so foreign. The pressure also felt appropriate; after all, the stakes were no longer bragging rights on the highest test score, but life and death.

I approached medical education the same way: my mentors were those who held me to the highest standards, which were at times overwhelming. During a subinternship in internal medicine, I would spend 30 minutes prerounding on a single patient in the medical intensive care unit because I knew my attending expected me to have a plan about everything, from the diagnostic analysis of the ascitic fluid, to the heptorenal syndrome, to the variceal bleed. My stomach might have been twisted in knots every morning, but I will never forget the pathophysiology and clinical manifestations of end-stage liver disease. Now on the other side, I appreciate the effort it takes on the part of attending physicians to instill and enforce these high expectations.

In the almost 2 decades since I graduated from medical school, I have observed physicians-in-training like a primatologist studies creatures in the wild. Instead of strategies of survival and socialization, I focus on styles of learning and decision making, and I have realized that there are 3 types of trainees: the Toddler, the Waiter, and the Captain. Each type has a unique style of learning, incorporating knowledge into clinical practice and working with other physicians. These trainee types have different strengths and weaknesses, and require different strategies by their attending physicians to inspire their best work.

The Toddler is the resident who already knows everything and appears unteachable. Like a 3-year-old, the Toddler will (figuratively, one hopes) stamp his feet and hold his breath until he gets his way with the patient. I certainly had Toddler moments as a resident. Like the time I had just read about the differential diagnosis of hyponatremia and felt that my attending physician couldn't possibly know more about it than I did; when I was convinced that the syndrome of inappropriate antidiuretic hormone secretion from a brain tumor was the only correct diagnosis, although the patient was in heart failure. Underlying my certainty was fear; I had to know everything or I wouldn't be able to save someone's life someday. But what I didn't realize was that residency is a safe cocoon where it is okay to be wrong, because there is a safety net of senior residents, fellows, experienced nurses, pharmacists, and attending physicians to break your fall.

So what's the best way for a resident to avoid being a Toddler? It is to recognize that you cannot, and should not, know everything. Even attending physicians don't know everything-but the difference is that they have the experience to know that common things are common, uncommon things are uncommon, and the right questions to ask when something doesn't seem right.

And what's the best way for an attending to confront a Toddler? The parenting classic The Happiest Toddler on the Block1offers advice to young parents on dealing with a difficult 3-year-old, but the advice works on adults as well. First, acknowledge the Toddler's feelings and emotions-recognize that it is scary not to know everything and to be wrong. When the Toddler calms down, you can explain why he or she is wrong. Parents worry that doing this will break their 3-year-old's spirit. I'm sure attendings worry about bursting a trainee's fragile confidence, but it is better to break a resident's self-assurance when you are still there to build it back up. It would be much worse for the resident to be dealt the crushing blow of a medical error through poor judgment down the line.

The Waiter is the resident who loves to take your order. As an example, consider a cardiology fellow who I trained a few years ago. A patient was on the table in the cardiac catheterization laboratory and I asked, "What catheters should we use today?" I expected the fellow to suggest the standard Judkins left and right catheters. Instead, he replied, "Whatever catheters you would like to use, Dr Kittleson!" Like Toddlers, Waiters are scared of their lack of knowledge and experience, but instead of belligerence, the fear manifests as subservience. While, as the attending it feels nice to be catered to, to be treated like an expert, and to have trainees hang on your every word, this is a bad approach to medical education. The resident who takes orders all day may learn slowly by example, but this is no fair practice for the day when the buck will stop with him or her.

How should a resident avoid being a Waiter? The best way is to have an opinion about patient management. The decision may be wrong, and that's okay. Understanding why a decision was wrong is a great way to prevent that mistake in the future.

For the attending physician, it is important to push the Waiter out of his or her comfort zone. The safety net of residency is a gift, a chance to save lives with training wheels on, and it is important to challenge the resident to treat it as such. Furthermore, create a safe zone for residents. As a resident, it is okay to be wrong as long as you can back up your medical decision with a rationale, and be willing to accept when your decision is wrong and why.

All residents should aspire to be Captains. Captains take ownership of their patients; they understand their responsibility is to steer the ship. They know important details: the purpose of every medication on the list, the plan for the day, and the long-range plan for the hospitalization. Captains are a joy; any resident can become a Captain if he or she is open to learning the art and style of medicine, is not scared to be wrong, and is ready to have an opinion and learn from it, whether he or she is on the right track or not.

As an attending physician, sometimes the path of least resistance is to ignore the Toddler, let the Waiter take your orders, and bask in the glow of a Captain. And even on that path of least resistance, the Toddlers eventually grow up and the Waiters get promoted to management. But by being hard on the Toddlers and Waiters, by having high expectations and enforcing them at every step, we are fulfilling our responsibility to train the next generation of physicians who might saves our lives someday.

My parents loved to tell me, "I'm not your friend, I'm your parent." I've taken this to heart as an attending. It is okay if the residents don't "like" me, because they are not supposed to. But I hope they will learn the good habits of a Captain to influence their practice of medicine for years to come.

References
1.
Karp H. The Happiest Toddler on the Block: How to Eliminate Tantrums and Raise a Patient, Respectful, and Cooperative One- to Four-Year Old. Revised ed. New York, NY: Bantam Books;2008.






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