Anne Vinsel, MS, MFA

Disclosures

November 26, 2008

Question
I was recently dismissed from my first residency position. I was told that I was not advancing as fast as expected, I was not asking questions enough, and my confidence was "scary." I need to find another position but I don't know how to become more employable.

Response from Anne Vinsel, MS, MFA
Project Administrator
University of Utah School of Medicine
Salt Lake City, Utah

First, congratulations on seeking information instead of crawling into a defensive shell. From the feedback they gave you, I can derive a pretty familiar pattern, and if you don't change it you will really hurt yourself in medicine. A friend of mine who is a division chief calls this pattern "the 6-month great hire," meaning a person who has lots of great qualities but who bombs quickly.

"Not advancing as fast as expected" usually refers to your learning curve, although it can also refer to not fitting in socially. Every medical site has expectations, usually unstated, about how quickly a new employee should be able to pick things up. The skills they are talking about are usually some combination of processing speed and rote memory. Some supervisors may tell you something once and expect you to remember it forever. Some might not plan on training you at all and just expect you to pick up everything you need by watching and learning for a short period.

Your choices are to either find a job with less demanding expectations (eg, slower pace) or to find a way to crank up your learning speed on the job. Some possible ways to do that would be to carry a small tape recorder so that you can review what people have told you (at home at night), practice improving your rote memory in your off hours, and selectively get instruction from people who are organized but kind.

"Not asking enough questions" is more difficult to interpret. A legitimate concern is that a resident who makes too many assumptions could kill patients. It's a fine line in medicine between asking too many questions (and thus wasting professionals' time) and not asking enough questions (which can create chaos among the staff and endanger patients and staff). Our office is always wary of new employees who just nod and never ask questions, particularly if they don't seem to be learning quickly (we can tell this from their performance). It usually signals cognitive overload and that the person isn't grasping the complexity of the situation.

You are in a bit of a "3 bears" situation here. You don't want to overreact and start making a pest of yourself with millions of questions; rather, you want to hit a "just right" level of questioning. Realize that many people in medicine were raised on the Socratic method, which requires the learner to ask questions to help the teacher fine-tune what they're teaching.

Now, "scary confidence" implies that you take on tasks you're not ready for, and in a hospital setting, that is just plain bad. Often, there can be disagreement about whether "scary confidence" is justifiable. You might think you are appropriately confident, but if your supervisor thinks you are overreaching, the higher status person will always win. You are a fresh graduate, you are probably young, and you may have cultural or generational differences with your supervisors.

For example, I personally worry about young people who say "okay" very quickly, particularly if they cut off some of the information I'm trying to convey. I have noticed that people who are assessed as "scary confident" also tend to be verbally expressive, prone to joking, impertinent with superiors, and they don't listen very well (before they disappear). Some medical students and residents, possibly due to nervousness, are so eager to impress that they are always getting a response ready instead of listening carefully to the person who is talking. Do you see yourself in this picture?

Think about how you'll want to change in your next position. I recommend laying back, listening hard, being sensitive to hierarchy (even if their ideas about computers are wildly outdated), and withholding any suggestions about how to do things better. Ask someone you trust to give you honest feedback once a week, then adjust your persona as needed.

You don't have to stay in this cautious, earnest mode forever, but it's a good way to start out. Eventually, as people learn to trust that you know what you're doing, you can be more yourself again.

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