Listen to the voice of experience

Navigating the academic medicine environment and other valuable lessons learned from the clinical training part of fellowship.

After five years of clinical training and a continuous call schedule, I am ready to put my pager away for some time.

I finished my clinical cardiology training last week, and yesterday I started my two years of protected research time. I have to admit that it feels good to go to bed at night without the threat of being awakened by the pager alarm.

Juan Rivera

During the past five years I have had a fair amount of interesting experiences and encounters that have helped me grow as a person and have contributed significantly to my medical training. Allow me to share with you some of the things that I learned, sometimes the hard way.

Breaking the inertia

This concept applies the most to those of us who at some point or another are required to take calls from home. No one likes to be awakened at 1 a.m. for a consult, especially if it leads to a hospital visit. It is not uncommon for doctors to be biased about the appropriateness of a consult even before answering the page.

“I bet that this is a bogus consult,” we think, and by the time we reach the person who is asking for our help and expertise, we have thought of at least five excuses not to see the patient or, in our own terminology, to block the consult.

I have learned that when a colleague calls you in the middle of the night he is asking for help. The best thing to do is find a way you can contribute to the overall care of the patient in question instead of looking for reasons to justify your lack of involvement. Breaking the inertia, that sluggishness that keeps you glued to your bed, is the ideal way of making sure that we are delivering the right care to patients and the right support to our colleagues. Besides, as you may have noticed, you spend more time arguing over the phone with the person calling the consult than going to the hospital and taking care of business.

Listen to the experienced

Residents and fellows tend to have a different level of respect for different attendings. I think that this is an inherent component of the academic medicine culture. In some instances, this will lead a naive resident or fellow to dismiss an attending’s clinical assessment and recommendation due to his perception of how smart or talented that particular physician is. This trainee may completely ignore the experience factor. Big mistake!

We learn the most by taking care of patients. Our clinical acumen develops through the process of pattern recognition, which in turn helps us identify those symptoms and clinical findings that don’t correlate with our presumptive diagnosis. Arrogance can make you deaf to the voice of experience. Even if the attending physician is ultimately wrong, if you listen, you will learn a great deal.

Swimming with sharks

Voltaire’s 1812 guide on how to swim with sharks describes perfectly the sometimes competitive and hostile academic medicine environment. Those rules that particularly fit:

• Rule 2: Do not bleed. “It is a cardinal principle that if you are injured either by accident or by intent you must not bleed. Experience shows that bleeding prompts an even more aggressive attack and will often provoke the participation of sharks which are uninvolved or, as noted above, are usually docile.”
• Rule 4: Get out if someone is bleeding. “If a swimmer (or shark) has been injured and is bleeding, get out of the water promptly. The presence of blood and the thrashing of water will elicit aggressive behavior even in the most docile of sharks. This latter group, poorly skilled in attacking, often behaves irrationally and may attack uninvolved swimmers or sharks. Some are so inept that in the confusion they injure themselves.”

All of you know who the sharks are in your institution or hospital, but be careful. “Not all sharks look like sharks, and some fish which are not sharks sometimes act like sharks.”

I suspect that as our careers evolve, the level of competition will intensify. I believe that the key is to treat everyone with the same level of respect, focus on your work, and find a group of colleagues with whom you enjoy collaborating.

Finding your comfort zone

You reach a point during your training in which you feel comfortable with yourself. In other words, you are happy and satisfied with the direction that your career is taking and the work that you are doing. Unsolicited and unconstructive criticism doesn’t bother you anymore. You develop your own character, work ethic and way of practicing medicine.

You become a better physician to your patients, a more focused researcher and a better teacher to those who are looking for their own comfort zone.

Juan Rivera, MD, is a Fellow at the Johns Hopkins Ciccarone Center for Prevention of Heart Disease and a member of the Cardiology Today Fellows Advisory Board. He also writes a cardiovascular prevention blog for Hispanics called Corazon Hispano. The blog can be viewed at: corazonhispano.blogspot.com.