3rd Year Reflections: Working with "Tough" Attendings

While intimidating, it is a pivotal chance to grow your expertise and ability to work in a collaborative environment

As a tutor and through my research, I have had the wonderful opportunity to work with many of my underclassmen in medical school. Many of them have just embarked on their 3rd year clerkship journey and I have been fortunate to share some advice having just completed my core clerkships myself. Perhaps the question I got most was how to deal with “tough” attendings, especially on services like surgery and internal medicine, where the culture may be a bit intimidating for newcomers. This had me racking my brain a bit, and I thought I would make a post about it for any rising 3rd years who may be interested.

When I talk about “tough” attendings, I am referring to ones that seem to point out flaws in everything you do, are not impressed even when you go all out, and in some instances may come off as rude. I am sure anyone who has completed medical training can relate to this experience in some way or another.

I consider myself lucky in the sense that any negative interactions with my 3rd year attendings were extremely far and in between. Nearly all of my attendings were fantastic teachers who were passionate about medical education and empathetic towards students. However, there were certainly a few who were more of an acquired taste where I had to work hard to build a good rapport with. Unfortunately, I have heard several stories among my peers where feedback had been given in a more discouraging and sometimes even insulting manner.

So here are my main lessons from Year 3.

Lesson #1: You are not alone, and this is part of the process.

It is very important to recognize that you are not the only student who feels this way and that this is a near-universal experience. Like I mentioned earlier, virtually every trainee that has gone through medical school and residency has had to deal with a tough attending.

However, it is also important to recognize that, for better or for worse, this is an inevitable challenge you are going to face for the rest of your career. Medicine is a demanding, high-stakes profession that necessitates you to work with many, many people. This includes your physician colleagues, nurses, scrub techs, physical therapists, hospital administrators, pharmacists, social workers, and about a thousand other professionals. The same goes for your patients, all with varying backgrounds and stories. Being able to quickly foster strong professional relationships with a variety of personality types is an important skill you need to learn to be a good doctor.

When it comes to attendings, this is no different. Attendings come in all shapes and sizes and have different affects and methods of teaching. I liken this to NBA players. You have some like Kobe Bryant who put in great effort to mentor and support young rookies. You have others like Michael Jordan who take a more harsh flu-game “tough it out for the rings” approach. Some may be like Jeremy Lin or Steph Curry, who keep spirits high and just seem to have fun playing the game they love. And you may have some like Kawhi Leonard, who are nonchalant and hardly show emotion toward anything, good or bad. Regardless of what attending you have, you should try your best to get along with them.

Let me make one thing clear - when I say “this is a part of the process,” there is a clear line between constructive criticism and unprofessional mistreatment. The latter is not part of the process. Unfortunately, mistreatment and somewhat of a hazing culture continue to pervade in medical training both at the medical student and resident level. If you feel that a line has been crossed, do not feel ashamed to have a conversation with your friends, residents, or even clerkship director.

Lesson #2: Don’t take things personally, and learn what your attendings value in clinical medicine.

There are going to be days where an attending cuts off your patient presentation because you’re going too long, makes you re-scrub because you did not perform correct sterile technique, or pimps you on the most obsolete factoid. And you will feel embarrassed by that. The important thing here is to not take things personally. At the end of the day, most attendings chose to be in an academic environment with trainees, and even if they have different ways of showing it, they want you to succeed and be the best physician you can be. Their critiques of you often have absolutely nothing to do with what kind of person they think you are. In these situations, it is important to maintain your composure and avoid acting emotionally or defensively.

I’d also go as far as to argue that you also should not let instances like these define your performance. Let me give you two examples.

On my minimally invasive surgery rotation, I used to be stress that no matter how much I read up on the anatomy and steps of upcoming procedures, I would get nearly every pimp question wrong. I seriously think I answered only a handful of these questions correctly over the entire 3 week period. However, I bonded and worked really well with the residents on the service and they were arguably the ones who were the closest to being genuine friends in real life out of any of my rotations. Even though I thought I was performing poorly, my evaluation ended up being good and the emphasis of my comments were directed towards how well I fit in with the team.

Similarly, my internal medicine attending once said to me that my ability to answer pimp questions during rounds was going to have zero bearing on my final evaluation. Instead, he said that what he cared about was good documentation, our teamwork skills working alongside the residents on a busy service, and an overall sense of improvement between our first day working with him and the last. Even though I got many questions wrong and occasionally floundered during my first week, he rated me well, noting that he observed the effort I was putting into improving my skills and my ability to develop a rapport with the team.

All of this is to say that different attendings value different qualities in clinical medicine and in their trainees. While some value a strong knowledge base, others may focus more on documentation, teamwork and personality, bedside manner, examination technique, professionalism, or simply putting in effort and doing the best you can. Learn what your attending values most, and try to perform best in those domains. If you are having trouble with this, it may be helpful to directly ask your attending during a feedback session - “What competencies should I focus on/are most important to master during this rotation at my level of training?”

I encourage my peers and seniors to retain this mentality throughout the entirety of training. In my view, part of the benefit of the medical training process is that you get to work with a large number of attendings in your journey. Even if you don’t like a particular attending, that doesn’t mean you can’t learn from them. Every attending I have worked with has given me at least one takeaway that I hope to incorporate into my practice philosophy in my future career.

Lesson #3: Expect to make many mistakes. Use criticism as an opportunity to grow, and actively seek it throughout your rotation.

This is probably the most important. It can be easy to feel discouraged when you feel like you’re doing everything wrong. It is imperative in these times to take a step back and reframe your mistakes into learning opportunities.

I kept a pocket notebook on my person at all times throughout my rotations, the usefulness of which merits its own post. Among other things, I often jotted down reminders to myself on areas to improve, content area weaknesses/pimp questions I got wrong, and even just general mistakes I had made. This served not only as a way to help me prepare for the next day’s work, but also to ensure that I never made the same mistake twice.

Unfortunately, mistakes are almost synonymous with 3rd year rotations. Expect to make a lot of them. You will be far from perfect when you start on a particular rotation and to be honest, you will still be far from perfect when you finish your time on that rotation. The important thing is to learn from each of them and even if you feel defeated, to actively seek even more criticism, even if it may hurt. Even if the list is long, it shows your attending that you are sincere in your desire to learn.

Lesson #4: No matter what, always have a smile on your face and act like you want to be there.

This is more general rotation advice, but I think it is exceptionally important. I alluded to this earlier, but a good attitude goes a long way. This applies for all rotations and all attendings.

I won’t lie, there were rotations that I loved and there were rotations that I did not enjoy as much. Even though I did not have any “difficult” attendings per se, I knew from day one that OBGYN was not the career for me. However, I showed up every day excited to see patients and eager to learn all things OBGYN.

Was some of this feaux enthusiasm? Possibly. But I told myself that if these were the only 6 weeks of my entire career I was going to be rotating on an OBGYN service, I was going to get the most out of it. Despite my lack of interest in the field, I showed up, engaged in morning reports, asked questions, read up on my patients, and only left when dismissed.

One thing to note here - it is one thing to show enthusiasm during a rotation you don’t really like that much. It is something else entirely to pretend to want to pursue a specialty when you don’t really want to. Most people will sniff through this in a heartbeat. I’d honestly say this hurts you as the bar will likely only be higher. You should not do this.

The fact is, most attendings in core rotations are completely aware that out of the medical students they get, only a certain fraction actually want to pursue their specialty. Although many try to inspire their students and market little-known highlights of their field, they recognize that students are interested in different things. The goal of most attendings is for their students to take away a few key skills that will hopefully use in whatever career they choose to pursue.

That being said, if you show that you have an open mind, a good attitude, and are willing to learn the basics of other fields of medicine (such as the one they spent years mastering), this will never go unnoticed during rotations. It can be as simple as asking a question on a complicated patient or offering to give a short presentation after rounds on a high-yield topic - showing some level of interest is all that really matters.

Working with a variety attendings can a double-edged sword - while you are certainly subject to working with a few “difficult” ones, this comes with incredibly learning opportunities and takeaways to shape your future clinical practice and prepares you for the reality that is working in the medical field. For any stressed rising 3rd year, don’t worry. Trust the process and you’ll learn to swim in the storm. Go kill it.

Author note: I particularly liked writing this one. If you can’t tell from my other posts, medical education is a big interest of mine. If this gets positive feedback, I’ll consider making this into a series with more posts aimed at other aspects of 3rd year rotations or medical school in general. Let me know.