OB Rotation – Dr. K’s Experience

Nothing is happening for me right now, but waiting for Match Day to arrive.  I’m not in any hurry to share, but I thought I might share yet another evaluation from the OB service, this one from my repeat OB rotation.  Unlike other rotations, I remember it was very difficult to even figure out what I was even supposed to do, and no one was helping me or making me feel like I was part of the team.  I was there to learn, but people expected me to know everything from the get go.  This is what happens when I run around like a headless chicken:

Program Director’s Notes:

Dr. Bob has completed 2+ weeks of his OB rotation and I called Dr. K to get a midpoint evaluation. She mentioned that Bob was improved from his previous rotation. He was working hard, trying to be involved and trying to learn and get along with patients, nurses, and attending. He was answering questions better, when evaluating Fetal Heart Tones he did OK and he was almost always at the nursing station. Unfortunately, when at the nurses station he seemed to be more interested in watching the monitor and paying attention to the computer, rather than actually going to see patients or watch for attending so he could be involved [Yeah – it was a pain to actually track down an attending who was always entering and exiting patient rooms left and right, and I was expected to somehow not be redundant while everyone was doing their own thing and I didn’t have any designated role in practice – FR].

He is really trying, but he is not that successful at being helpful.  One evening at 6:50 he scrubbed out of a C-section due to his shift being over, and then documented the surgery with a blood loss of 1000 cc’s. The actual blood loss was half of that and she had to document that more fully than normal and address his mis-documentation which cost her time and she worried that may have exposed her to some risk should something unexpected happen in the post-partum period [She did tell me to document 1000 cc’s, but then she changed her mind, and now she is blaming me – FR].

They were getting cord blood after a delivery which was not totally normal and Dr. K was teaching him about how to differentiate between the umbilical vein and artery, why that is important and how to draw it. Dr Bob did not seem to understand the difference in expected values for adult blood gas values and newborn blood gas values or even why they should care about venous vs arterial. He then got venous blood instead of arterial and when Dr. K was again instructing on technique and why the correct blood (arterial vs venous) he raised his voice and said “That is what I am trying to tell you!” with an angry tone, that Dr. K found to be disrespectful to her, and certainly would not have been tolerated when she was a resident. She summarized that he just has no awareness of how to interact with people, how he seems to come across or how to apply the medical knowledge he has to patient care. Another example of this was on the day prior to our conversation who was being induced for Pregnancy Induced Hypertension, he wasn’t documenting and couldn’t tell Dr. K what the BPs were, which she felt was substandard care [It was a no-win situation. I was afraid to document anything because she would dispute my records later on, or tell me that I was wasting her time. When I didn’t she would tell me I was providing substandard care. As to the yelling, I may have been emphasizing that I knew what I was doing, and I knew the correct procedure after they pointed it out. It wasn’t like the attendings weren’t shouting at each other as well, it’s a stressful environment. Singling me out was very hypocritical. – FR]

She also noted that his documentation is poor. She expects residents to be rounding and documenting their patient encounters every 2 hours. The other residents have been doing this for years in our program. She noted an example from 2/16/10 that she pulled up while we were talking. There was documentation from herself at 6:30am (admission), 10:20, 11:30, 12:50, 13:54, 15:47, and 17:14. Dr. Bob documented an admission H&P at 7:33 and notes 12:27 and 14:45, was noted to be there for parts of the pushing but would frequently leave the room and then wanted to do the delivery.

When asked about whether she thought he would receive a satisfactory evaluation this month, she reported that she was conflicted. He was better this month, but clearly not a the level expected of a PGY-1 resident 2/3 of the way through their first OB rotation yet. She did not think he would successfully pass, but would hate to fail him, partially because then she would have to work with him again and that has not been pleasant at times for herself or some of the nurses. She decided that a marginal pass is most likely what his final evaluation will be, unless there is an enormous change in the level of his performance. Given his difficulty with feedback and incorporating teaching into practice, she felt that was unlikely.

 

OB Rotation Experience – Dr. G’s Perspective

Looking back at my evaluations still makes me cringe sometimes, and the OB rotation was arguably one of the worst in my memory. I remember being confused about what I was supposed to do, feeling redundant since the nurses and the attendings did everything, and the nurses and the doctors around me were cold and hostile.  Here is an account from Dr. G, one of the PGY-2s.  I won’t waste time correcting the inaccuracies of the program director’s account, but it goes without saying that a lot of details are warped as stories are passed from one person to the other.

Begin

Dr. G approached me (the program director) to share some recent concerns from OB nursing and attending on the OB rotation at E Hospital. Dr. G is the night senior, so interacts with Bob twice a day and the nurses all night long. She has been hearing concerns about Bob for the past week and a half and has shared these concerns with Bob. Bob responded by stating that he had not heard any of these concerns from nursing and so he did not feel they were valid. Dr. G was concerned that if Bob did not make significant changes, that he would not succeed in his current or future OB rotations.

The OB nurses report that Bob has been polite and respectful, but very quiet. They report that he has been avoiding cervical examinations, deferring to nursing to perform these in spite of clear expectations expressed to all residents that they are expected to perform these (with a chaperone if male resident). At times even deferring when nurses have asked him in front of the patient if he would like to check their cervix for progress and he has told the nurses to just go ahead and check.

The OB nurses are concerned that he “just doesn’t get it”. He is not confident in even basic medical skills and seems to have a hard time knowing what to be concerned about, what information to gather from patients and the chart and how to put it together into clinical management.

He is slow in getting work done. An example is with a patient of Dr. D that needed to have orders written after a phone consultation between Bob and Dr. D. Bob mentioned that he would get to it after going to see a patient in triage. He did not return, so they were written by someone else and he was not witnessed to have checked to be sure they were written.

Dr. M mentioned to Dr. G, that Bob was very passive and missing opportunities to participate in deliveries. On one occasion in particular, they were both gowned and ready for the delivery and Dr. M had been managing much of the descent of the head with pushing from the pregnant patient and then Dr. M invited Bob to step up and participate in a hands on way and Bob looked at him and stayed back. Dr. M then completed the delivery himself.

Nurses have noticed that some patients that were originally interested in having a resident involved with the delivery, changed their mind and specifically asked to not have a resident after Bob was to see them. It is unclear exactly why this is, but they have not really seen that with other residents. Some of these patients were then OK with the night senior after Bob left the labor desk. Dr. G did inquire with some of these patients about these reasons and she heard nothing specific, but the term “creepy” was mentioned more than once. This last piece of feedback was not expressed to Bob, but he was encouraged to work on his interpersonal skills and interactions with patients.

Nursing mentioned that Bob is “poky” about getting to patient evaluations and seems to do things on his own time. They give an example of a patient needing to be evaluated while Bob was eating. He did not seem interested and waited until he had finished eating to finally assess the patient. Nurses felt that this was inappropriate.

End

I know why they thought I was “creepy” – because the nurses were discouraging the patients from seeing me. One theory: One nurse saw me inadvertently pushing an abdomen too hard, thought I was “rough”, and told the other nurses about it, and rumors got out of hand.