Introduction
This scenario provides anticipatory guidance for pre-clinical medical students to help them prepare to enter clinical training years, guidance for 3rd year students who need help addressing the challenges of clinical training, and insights to help faculty who guide these students.
Your role: Throughout this activity, you will play the role of a 3rd-year male medical student, Will M, who is struggling with several issues related to working in the clinic in 3rd-year clerkships. Occasionally, you will be asked to make a choice as if you were him.
By experiencing the story of Will M, you will vicariously experience (or recall) the challenges of third-year clinical rotations including learning to work on a clinical team. You will learn skills that help manage the challenges.
Example Scenario – Will M
Your Role: In the role of 3rd-year medical student, Will M, your concerns are:
- You feel inadequate in dealing with patients’ emotions after a challenging situation with an upset patient.
- After a harsh critique you received on your performance review in the clinic, your self-esteem is low.
- You are uncertain to take initiative and when it is okay to ask questions.
Getting Support from a Medical Student Peer:
Scenario: You are a third-year medical student and you see your neighbor, 4th-year medical student Brittany, who lives in the same apartment complex. You would like to talk with her, since she would understand the challenges of making the transition to 3rd-year clinical training and might have ideas on how to navigate them better.
You: Hi, Brittany. Good to see you. Can we talk?
Brittany: Sure. What’s up?
You: I’m struggling with some things in clinic. I’d like to hear your perspective.
Brittany: I’m not sure I’ll have any answers, but I’m happy to share anything useful I can remember.
You: Thanks! Sometimes it helps just to have a sounding board.
Clinical Clerkship Challenge: Learning Skills in Interacting with Patients
Scenario: Working in the clinic brings new challenges requiring skills in relating to patients. For example, you struggle with how to respond to strong emotions in a patient:
You: I have no idea what to do with patients who are crying.
Brittany: That can be hard. Can you give me an example?
You: I had to see a patient who was crying after she received some bad news. I didn’t know what to do. So I just introduced myself and she just kept crying.
Brittany: What did you do?
You: I asked if it was okay if I sat with her. She nodded but kept on crying.
Brittany: I think that’s actually pretty good. You just let her sit and feel what she was feeling. I think just being present and witnessing what a patient is feeling is important. [Validation]
You: Yeah, I guess so. So, I told her I’d listen if she wanted to talk, but she didn’t seem to want that. I explained I was supposed to update her history but could come back, and that’s what she chose.
Brittany: You did a great job of paying attention to what she needed. You didn’t try to force your help on her, but were available. You let her decide if she felt up to doing the history right then. I think you handled it well. [More Validation]
You: But I felt so inadequate.
Brittany: Sometimes you can’t fix things, you know? Often, you won’t have the luxury of having enough time to spend. But when you do, you can offer support as you did. Just the fact that you were affected by her crying shows what a caring person you are.
[Recognize strengths]
Clerkship Challenge: A Critical Review on Clinic Performance
Scenario: On another day, you see Brittany while coming in the door. You have just received the following report and are feeling discouraged.
Mid-Clerkship Evaluation of Student H&P
Student Name: Will M
Submitted: Today’s date
Professionalism:
Acceptable: Respectfulness, honesty
Area(s) of Concern: Work ethic/dependability, motivation, excellence
Competency:
- Below expected performance level (!):
- History Taking: Missed key features of symptoms.
- Written Medical Record: Missed key features of symptoms.
- At expected performance level:
- Clinical reasoning and decision-making.
- Medical knowledge.
- Interpersonal and communication skills.
Submitted by: H.W. Attending, M.D.
Brittany: What’s going on? You look pretty down. [Open-ended question]
You: The attending in my clerkship gave me a really negative performance review today. Not only did they notice every little detail I missed in my patient presentation, but they also explained in detail the impact of each mistake on the patient. I feel like a complete failure.
Brittany: It can be hard to hear critiques like that. But, when I look back on 3rd year, I think that detailed critiques are where I learned the most. You’re actually pretty lucky to have someone who takes the time to explain the impact instead of just pointing out your errors.
[Empathy, reframing]
You: I suppose you are right. What hurt the worst is that he assumed I’m not motivated and don’t care, and that’s not the case.
Brittany: I know what you mean. There are other possible reasons. What was it for you?
You: It’s more that I didn’t anticipate the rapid pace of clinic compared to working with standardized patients. I spent to much time on the first questions and then I ran out of time.
Brittany: Clinic is different from standardized patients, isn’t it?
You: Yes! So, I missed getting some key details of her history. I never used to have problems with history-taking or case presentations before, so I didn’t prepare much before starting the clerkship. It was an incorrect assumption, not a lack of caring. And the patients I was assigned to present were very complex. I didn’t know how to structure my interview or presentation.
Brittany: Well, you just figured out one answer: It’s important to take initiative, and prepare by reviewing what you were taught in pre-clinical classes on history and case presentations. But if you are still overwhelmed, you need to ask for help when you need it. Let them see how motivated you are.
You: Thanks, Brittany. Those are all good points.
Reviewing Challenges from a Positive Perspective:
Scenario: You are having a hard time enjoying the clerkship learning experience because you struggle with some of the challenges. To get in a more positive frame of mind, you go through a set of questions you learned for making sure you notice the positive experiences in your training called, “Appreciative Inquiry Principles.” The questions basically ask, “What Went Well?”
Appreciative Inquiry Principles
Inquiry 1: What is something that went well for you today?
You: I felt relaxed enough when taking a patient’s medical history to enjoy getting to connect with her as a person.
Inquiry 2: What was a success that you had recently?
You: I got to remove some sutures. It went well!
Inquiry 3: Talk about a recent positive experience in your work or personal life.
You: The attending said she appreciated how well we managed a heavy patient load yesterday. I was glad she noticed.
Inquiry 4: Has a patient or family member told you that you made a difference?
You: Not yet, but I’m looking forward to it.
Inquiry 5: How do you help to make the workplace more productive and positive?
You: I pay close attention and make sure I’m doing my part to the best of my understanding.
Inquiry 6: Have you noticed a team member go beyond the call of duty sometime this week?
You: Yes, the senior resident. He’s been a great role model.
Inquiry 7: Can you recall a situation this week in which you had a chance to learn and grow?
You: Wow, when I think about it, there have been so many!
Inquiry 8: Think of a recent successful team project. What made the team successful?
You: Things go well when everyone shows up and plays their role. I just need to get clearer about roles.
You: I’m feeling more positive after this review and encouraged to do what it takes to get a better understanding of my role.
Clerkship Challenge: Learning Teamwork
Scenario: You think your poor performance review was partly accurate and your own fault. However, you also feel it was partly the team’s fault for not helping you more and you feel a little angry about that. You are confused because you don’t know what you should know already or learn on your own and what it is reasonable for you not to know and when it is okay to ask questions. You do not ask for help, because you think it could get you another bad review.
To help you decide how to handle this situation, you refer to a list of steps for better teamwork that you learned in a pre-clerkship class. [See INTERVENE steps described in the module accompanying this scenario]. The following steps seemed most relevant:
2. Determine the best management strategy for the situation (Expand your choices to view feedback):
What is the best management strategy?
Different situations call for different strategies. Of the following options, select the best for you in this situation (feedback is color-coded to reflect the best (green), neutral (yellow), and the worst (red) strategies:
Avoid – Denying the existence of conflict.
Avoidance was actually partly the strategy that you had been using. As a result, you had not made your training needs known. This might be a good strategy in the short term, but not a long-term solution. Choose a better option.
Accommodate – Letting the other party decide
This was actually partly the strategy that you had been using and as a result, you had not made your training needs known. Choose a better option.
Adaptation – Working with or around differences
You were sort of trying to use this approach. It helped you get along with the team but didn’t meet your needs. Choose a better option.
Compete – Aggressively pursuing ways to achieve your win
Competing aggressively is probably not the best approach when new on a team. Choose a better option.
Collaborate – Actively looking after your own interests but not losing sight of the interests of others.
Collaborating is the best approach for you at this point. There is much you do not know and need to learn. You may need to speak up if the team is expecting more of you than you can handle. You also need to look at yourself and make sure you are doing as much as possible in your role as you understand it.
4. Select the best setting and person for the encounter
5. Enlist help from others.
Scenario: You decided what you need most is mentoring, and the resident, Dr. John Benther, having gone through 3rd-year clerkship only 3 years earlier, seemed like a good option.
You: Hi, John. Could I have around 10 minutes of your time for some mentoring-type questions, in private, if that’s okay?
Resident: Sure, let’s go to the resident’s office. No one is there now…..How can I help?
Of the following, what do you want to say next?
My first question is: How do I figure out when to say I’m in over my head and need some help and when to keep struggling and figure it out for myself?
In this choice, you take as much of the responsibility as you can and ask for the help you truly need.
My first issue is you don’t make it clear when it’s okay to ask questions.
In this choice, you don’t acknowledge much of the responsibility and take a blaming tone. Please try again.
Resident: That’s a good question! I’d say it’s good to figure out as much as you can for yourself. But get some help when it could put the patient at risk or interfere with the smooth functioning of the clinic. And if you have some doubts about which category it is, ask me or someone more senior if I’m not available.
You: Thanks! That helps. My other question is how to structure my write-up of the History in a complex case like the one I saw yesterday. I revised my write-up since it was incomplete. It would be a big help if you could look at it and point out any continuing problems that you see.
Resident: Sure. Let’s take a look…..
Scenario Summary:
3rd-year medical student Will M. employed skills to help him adjust to some of the challenges of clinical training:
- To deal with feelings of insecurity about how he responded to a patient who was crying, a peer helped him see that he responded well by focusing on being present and compassionate, which helped him develop confidence.
- To deal with a critical clinical performance evaluation, he learned to focus on the part that would make him a better doctor and notice the positive aspects of his clinical training.
- To deal with the need for better understanding of his role on the clinical team and his need for more guidance, he reviewed and applied steps for better teamwork, particularly seeking mentoring from a medical resident while making it clear that he wants to take as much responsibility as is appropriate.
Activity Learning Points Summary
Learning points from this module and scenario include:
Clerkship students sometimes must deal with strong emotions in others: When a patient or colleague is struggling with overwhelming emotions, remember that the student can offer supportive presence can be helpful, even if they cannot think of a thing to say beyond saying they’re sorry to see how upset they are and offering to listen.
Dealing with criticism from clinic superiors or team conflict:
Sometimes it is important for clerkship students to speak up in a learning environment and ask for something to change. At other times, they may elect to focus on the positive and the learning experience (ask, “What went well?) and what can be used to become a better clinician and let the rest go.
Appreciative Inquiry: Questions students can ask themselves to notice the positives in their work, teamwork, or life:
- What is something that went well for you today?
- What was a success that you had recently?
- Can you tell me about a recent positive experience in your work or personal life?
- Has a patient or family member told you that you made a difference?
- How do you help to make our workplace more productive and positive?
- Have you noticed a team member go beyond the call of duty sometime this week?
- Can you recall a situation this week in which you had a chance to learn and grow?
- Think of a recent successful team project. What made the team so successful?
Clerkship Students Working with Team Conflict: The acronym INTERVENE can help students remember the steps that can help improve team functioning when there is conflict in a team:
- Intervene early
- Note the best management strategy
- Think through other factors at play
- Elect the encounter
- Regulate the amount of feedback
- Verify the common goal
- Explore intentions
- Narrate specific examples and provide alternatives
- Enlist help from others
References
AMA. Practice transformation series: Using appreciative inquiry to foster a positive organizational culture. 2016.
Bird A, Tomescu O, Oyola S, Houpy J, Anderson I, Pincavage A. A curriculum to teach resilience skills to medical students during clinical training. MedEdPORTAL.2020;16:10975. https://doi.org/10.15766/mep_2374-8265.10975
Appendix D. Lesson Plan – Difficult Team
Houpy JC, Lee WW, Woodruff JN, Pincavage AT. Medical student resilience and stressful clinical events during clinical training. Med Educ Online. May 2, 2017;22(1). doi:10.1080/10872981.2017.1320187. PMCID: PMC5419301. PMID: 28460570.
Lorenzetti C, Jacques CHM, Donovan C, Cottrell S, Buck J. Managing Difficult Encounters: Understanding Physician, Patient, and Situational Factors. Am Fam Physician. March 15, 2013;87(6):419-425. PMID: 23547575.
May N,Becker D, Frankel R, Haizlip J, Harmon R, Plews-Ogan M, et al. AppreciativeInquiry in Health Care: Positive Questions to Bring Out the Best.Brunswick, Ohio: Crown Custom Publishing, Inc.; 2011.
Saltman DC, O’Dea NA, Kidd MR. Conflict Management: A Primer for Doctors in Training. Postgrad Med J. January 2006;82(963):9-12. doi:10.1136/pgmj.2005.034306. PMCID: PMC2563732. PMID: 16397073.
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