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Strategies to help you deal with difficult attendings

Talking about expectations and seeking support can resolve problems, bolster trust and enhance needed skills

From the January/February ACP Observer, copyright © 2004 by the American College of Physicians.

By Christine Kuehn Kelly

Unhappy with his residents' patient presentations, the attending ordered them to spend more time on presentations—between three and four hours a day more, to be exact. When housestaff found themselves struggling with the new workload, they tried to talk to the attending.

"I said the format wasn't working," recalled Kavita K. Patel, ACP Associate, who was chief internal medicine resident at Portland's Oregon Health & Science University. "Could we make rounds more effective by having one intern do the work and the other present?"

The attending, however, rejected her idea outright. "This is how I do things," he insisted. Like many other residents in similar situations, Dr. Patel decided to drop the issue and wait out the rotation.

While most attendings behave professionally, the lopsided balance in power inherent in the senior-junior colleague relationship can cause major problems. "As a chief resident, I saw other residents have catastrophic relations with attendings," said Dr. Patel, who is now a Robert Wood Johnson Foundation clinical scholar at the University of Southern California, Los Angeles.

Attendings can over- or undermanage residents, act in a preemptory manner or even be insulting. They may punish residents for mistakes—or publicly humiliate them.

Or they may unreasonably stretch out rounds, a key issue for time-pressured housestaff. "How rounds are conducted—and the proportion of time devoted to them-tends to be a major issue for residents," said Holly J. Humphrey, ACP Member, professor of medicine and dean for medical education at the University of Chicago Medical School.

Some attendings want housestaff to round for hours, which cuts into required conference time. Others may want residents to round late in the day, after they have done all their procedures.

And others never seem to trust the residents working with them. "The most common complaint of residents is attendings who are not trusting and yielding-and who micromanage residents," said David L. Battinelli, ACP Member, past president of the Association of Program Directors in Internal Medicine and an associate professor at Boston University School of Medicine.

Whatever the cause of the friction, the end result is disgruntled interns and residents. "I had a negative experience and I never forgot it," said Dr. Patel. "I wish I would have pushed more on the behalf of my team."

Addressing problems

Educators say residents owe it to themselves and their colleagues to speak up when they have problems with an attending. Resolving problems that affect learning will not only improve your education, they point out, but can help you develop communication skills you will need throughout your career.

"Letting superiors who have behaved in a specific way know that you either disagree or need to understand their thinking—these are useful problem solving skills," Dr. Humphrey said. These are the same skills, she added, that you will need when interacting with patients and their families or working as part of a research team.

Residents and interns should also keep in mind that struggling to improve communication with an attending they don't see eye-to-eye with will not adversely affect their evaluations or letters of recommendation. "Any one interaction meant to improve dialogue can't possibly result in something negative from a learner's point of view," Dr. Battinelli emphasized.

When a problem arises with an attending, experts say, residents shouldn't simply let it go. Gordon L. Noel, FACP, chief of medicine at the Portland VA hospital and professor at Oregon Health & Science University, recalled a situation where a cancer patient decided he didn't want all possible care, but his family disagreed.

When the residents tried to negotiate, the attending told the family he was there "to rein in the residents." Later in the rounds, the residents went to the attending to defend their efforts. The attending ended up returning to the patient and family to clarify his comments, and the residents felt validated.

Systems approaches

Many residency programs have systems in place to address the power differential—and work out problems—between junior and senior colleagues. Educators say that nonpunitive reporting systems are key.

"Our residents know that when they have a problem, they can move it up the reporting chain and be protected in doing so," Dr. Noel said.

The first line of defense is the chief resident, who typically has been trained to help his or her colleagues. If the chief resident can't resolve the problem, the service chief and program director may be brought in. Residency directors clarify standards of conduct for both attendings and residents and will intervene if conduct falls short.

You also can look outside your institution for coaching and support, to colleagues from medical school or a community-based physician. You may want to start a dialogue by saying: "I'm having a difficult situation with a physician. I could use some help. Do you have some ideas?"

Some international medical graduates complain of having to cope with attendings who automatically question their competence. The program director is the best person to handle this type of serious potential bias, as well as any gender or racial issues.

Residents also need to take advantage of opportunities built into their program to air grievances. At Oregon Health & Science University, for example, attendings and residents are debriefed at the end of all rotations, Dr. Noel said. This creates an opportunity to ferret out attendings who are too involved—or too hands-off.

When issues turn up in those discussions, he explained, the program director can take appropriate action. Dr. Noel said that he encourages residents to bring up problems, because changes can benefit both current residents and future housestaff.

And residents at the University of Chicago's internal medicine program receive training on how to deal with complicated team dynamics. In addition, Dr. Humphrey said, faculty are reminded that residents are still learning, an important factor to bear in mind when a resident makes a mistake.

"While a very important piece of learning involves the experiential component of taking care of patients," she said, "that doesn't mean the resident is an independent practitioner."

Tips to address problems

While educators acknowledge that it's never easy to stand up to a senior colleague, they suggested the following tips to help manage interactions with difficult attendings:

  • Understand expectations. Much of the friction between residents and attendings comes from misunderstood expectations. That's why you should seek out your attending—even before the rotation begins.

    "In our experience, the single factor that correlates with high resident ratings for attendings is when the attendings sit down with the resident at the beginning of the rotation," Dr. Battinelli said. Attendings typically discuss how teaching and evaluation will be conducted, and they negotiate goals with the resident.

    If the attending doesn't seek you out, arrange a meeting or initiate an e- mail dialogue.

  • Get feedback early. Don't wait for the end of the rotation for feedback, said Bryan C. Batch, ACP Associate, chief resident in internal medicine at Boston University Medical Center. Solicit an informal evaluation halfway through the rotation so you don't receive any unpleasant surprises at the end.

    And if a final written evaluation is negative, be sure to ask for a meeting with the attending to discuss what went wrong.

  • Show respect. "I found it works well when I attempt to validate the attending," Dr. Batch said. If, for example, an attending wants to spend several hours teaching on a day that a patient needs extra care, Dr. Batch suggested making statements such as, "I really want to learn from you; I believe you can help me become a better doctor. But I can't devote my full attention to you today. Is there a better time to do this?"

    Don't use the patient as an excuse for being too busy—but see if caring for the patient may create a teaching opportunity for the attending.

  • Provide details. When talking about a problem or incident, be specific about your complaints. Avoid personality issues and stick to the facts, such as, "Twice last week we waited for 45 minutes to begin rounds. Is it possible to coordinate a later time to see patients?"

  • Be realistic. If you can't work out your problems one-on-one with an attending, take a step back and consider how serious the problem is before you take it any further. Residents often feel their careers can be damaged by an attending, but even negative evaluations are not likely to hurt you, as long as they are infrequent. After all, anyone can have a bad month. If you decide to go further with your problem, document what transpired, including how you solicited the help of others such as the chief resident to resolve the situation.

  • Know your rights. Review your residency contract and green book. These documents clearly define grievance issues and due-process procedures if a problem cannot be resolved at lower levels.

  • Participate in a housestaff association. These associations, which are currently active in more than 50 internal medicine programs, deal with everything from attending issues to planning social events.

  • Keep a journal. Finally, Dr. Noel offered this suggestion: Writing about what is bothering you with an attending can help you feel less isolated.

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

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