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Working with a tough attending? Try these techniques

Opening the lines of communication is just the first step to helping resolve problems

From the October 1999 ACP-ASIM Observer, copyright © 1999 by the American College of Physicians-American Society of Internal Medicine.

By Christine Kuehn Kelly

The stories are the stuff that television dramas are made of: An overbearing attending threatens a resident's career, tells an international medical graduate (IMG) that she is taking jobs away from Americans or repeatedly humiliates residents in front of patients and colleagues.

While most attendings behave professionally, there always seems to be one—or one you've heard of—who downright mistreats you and other residents. In a survey of more than 1,700 residents and attendings published in the Journal of the American Medical Association in April 1998, 93% of residents reported experiencing at least one incident of perceived mistreatment. According to the researchers, "The highest percentage [of incidents] was recorded for public humiliation or belittlement. Attending faculty and residents at a higher level were mentioned most often as the source of the mistreatment."

Many residents try to simply ignore attendings who treat them poorly, knowing that their troubles will vanish when they move to another rotation. Certain problems, however, go beyond what junior colleagues should be expected to tolerate from senior colleagues. If you are repeatedly singled out when you make a mistake, or are denied opportunities or verbally abused, educators and residents alike say it's time to start looking for a solution.

Identify exactly what attendings expect of you to eliminate later surprises—and problems.

"If the attending is being inappropriate and your learning is being impaired, you need to stand up for yourself," said Elizabeth McKinnis, ACP-ASIM Associate, chief resident at the University of Washington. "You owe it to yourself and to others who will be following you."

While experts acknowledge that it's never easy standing up to a senior colleague, they say you need to prevent the problem from getting worse. Here is some advice from educators and residents who have been there.

Talking it out

When a serious problem arises with an attending, your first recourse is communication. That's why you're better off, say educators and residents, communicating with attendings about goals and expectations as soon as you begin a new service, instead of waiting for a problem to develop.

Being proactive is key to heading off problems, advised Dr. McKinnis. "The first day I go into a service, I try to meet with attendings," she said, "This has worked well for me."

Start by identifying what the attendings expect of you. Misunderstanding expectations is where most of the friction between residents and attendings occurs. Understanding what attendings expect will clue you in on how the rotation will be managed and will eliminate surprises. In many cases, just having the discussion can lead to changes.

"Whenever I've had overbearing attendings who I thought were usurping my role, I've had a frank discussion with them," said Alex S. Niven, ACP-ASIM Associate, Chair of the College's Council of Associates and a first-year pulmonary fellow at Walter Reed Medical Center in Silver Spring, Md. "The discussion invariably has made me feel better."

When talking about a specific problem or incident, be specific about your complaints and ask the attending for feedback on your performance. If you can't work out your problems one-on-one with the attending, take a step back and consider how serious your grievance is—and if you should take it further.

If you do decide to pursue the matter, be prepared to work with the people in your program who are at your disposal. Dr. McKinnis recalled one attending who was so condescending that residents could not even begin to talk to her. "She was making life unpleasant, to the point of making interns cry," Dr. McKinnis said. "I ended up talking to my chief resident, who took up the issue with the medical education supervisor." That attending's interaction with residents ended up being limited as a result.

After the chief resident, the residency program director is your next line of defense. Residency directors must make standards of conduct clear for both attendings and residents, and they are expected to intervene when conduct falls short of these standards.

Subspecialty department chiefs can also intervene on your behalf. "There was a case several years ago when an attending made a daily practice of humiliating the residents on rounds," recalled Dr. Niven. "The attending received uniformly bad evaluations at the end of the rotation, which prompted an investigation by the program." The attending was eventually reassigned to duties that did not involve teaching housestaff.

Taking the problem to an objective authority figure can also be the best approach if a resident experiences overt prejudice. Some IMGs, for example, complain of having to cope with xenophobic attendings who automatically question their competence.

Frequently the best way to deal with problems like racism is to bring substantive evidence to the program director. That person has the authority—and the obligation—to resolve the problem. "The issue probably won't go public," said Lazaros Nikolaidis, ACP­ASIM Member, third-year cardiology fellow at Western Pennsylvania Hospital in Pittsburgh. Instead, an announcement is usually made that the physician will no longer be covering certain services.

Before pursuing that route, however, prove your abilities to a skeptical attending. Establishing your competence is critical for IMGs, pointed out Dr. Nikolaidis.

If your program is more autocratic than democratic, a house officer association might help you become more proactive.

"Don't isolate yourself," advised Dr. Nikolaidis, who earned his medical degree in Greece. "Take the opportunity to make presentations and otherwise show that you can express yourself clearly. You need to maintain the attending as a valuable resource."

Strength in numbers

Other times, problems exist not because of your relationship with any one individual, but because of the way a program is structured. A common example is when a program makes major decisions that affect its housestaff without considering residents' needs. "When residents aren't notified until the last minute about things like changes in the program, it gives us a sense of lack of planning and foresight," said Paul Jung, ACP-ASIM Associate, a second-year resident at MetroHealth Medical Center, an affiliate of Case Western Reserve University, in Cleveland. "We don't want to just be told, 'You need to do another month in the intensive care unit.'"

Dr. Jung said that his program gets around such problems by working closely with residents. "When there was an unexpected shortage of junior residents during the coronary care rotation, we were asked to increase our coverage," he said. "We came up with two on-call options that we presented to the program director, and we were allowed to choose one."

"This is part of how we encourage our residents to be autonomous, independent thinkers," said Case Western internal medicine program director Michael J. McFarlane, ACP-ASIM Member. "It's not quite a participatory democracy, but we are close."

If your program is more autocratic than democratic, a house officer association might help you become more proactive. These associations, which are currently active in about 50 internal medicine programs, deal with everything from problems with attendings to planning dinner dances.

At Tulane University Medical Center in New Orleans, for example, the Tulane Housestaff Association is working on issues ranging from whether residents can bring their families when they travel to out-of-town rotations to how to beef up security and Internet access.

One final word of advice: While there are several mechanisms to help you deal with problem attendings, experienced residents say that you should complain only when you have a serious problem with a staff physician's behavior. Attendings are ultimately responsible for patient care, and residents must respect that responsibility.

Josh E. Lowentritt, ACP-ASIM Associate, a nephrology fellow at Tulane, said that attendings are often hard on residents for a good reason. "Medicine is a tough place," he said. "You need to be able to back up what you are talking about. If you don't and some attending smells blood, he has a right to bore in on you. It will make you better for the day when you're out of training and are responsible for people's lives."

Christine Kuehn Kelly is a Philadelphia-based freelance writer specializing in health care.

A problem-solving checklist

Keep these points in mind as you try to resolve problems with difficult attendings:

Get out the journals. When there is a difference in opinion, document your diagnostic and treatment decisions. "Evidence-based literature is the indisputable point of reference," said Alex S. Niven, ACP-ASIM Associate, Chair of the College's Council of Associates and a first-year pulmonary fellow at Walter Reed Medical Center in Silver Spring, Md. Once you have presented valid information, the difference should narrow or disappear.

Avoid snap decisions. If you're stressed out from an incident, don't decide to take drastic actions. Consider your options carefully before you decide to confront an attending.

Know your rights. Read through your residency contract and your green book. These documents clearly define grievance issues and due process procedures.

Follow the chain of command. If you can't resolve an issue one-on-one, talk to your chief resident first, then go to the program director. The program chair is a last resort. For an objective opinion, you may want to talk with a physician from outside the hospital.

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