Extension

By Tim Lahey

Every March I run the last required course at our medical school. It’s a three-week-long, 47-hour sprint – a sort of boot camp for professional formation. We polish clinical skills, revisit foundational sciences, let students pick from a menu of interesting tutorials, and discuss professional formation.

Students grapple with hypothetical gastrointestinal crises on scatalogically-named student teams. They resuscitate rubbery patients with various flavors of hypotension. I don a sparkly red bowtie to MC a game show called Antibiotic Jeopardy.

Throughout, we discuss the evolution of their professional identities. I ask how their idealism has changed during medical school, and every year over 60% say it has waned. We share the stories that shape us, and how they can stay true to the values that brought them to medical school in the first place. Then they hand in a tall stack of confidential essays that I reply to on nights and weekends right up until the day they speak the Hippocratic Oath. 

This is a special class. They knock my socks off with their insight, and vulnerability.

The course also includes the routine mechanics of instruction. PowerPoint slides are exchanged. Scheduling conflicts come up. Audiovisual meltdowns occur.

Recently, I got an email that felt routine at first. Then I started to think it, too, was about professionalism.

The student wrote, “I’m wondering if I can get an extension on the due date for the complete physician essay.” He was attending an optional scientific conference out of town and hoped he could have more time to complete the assignment. It was due in 10 hours, and the conference was busier than expected.

Here’s my response:

I have a complicated answer to your question, sent with a smile.

The short version:

You won’t fail [the course] if you blow this deadline, and it’s not a big deal, but I want you to think through whether it is wise to ask me this.

The longer version:

For the rest of your life, your professionalism will be judged on how well you keep promises and execute on your obligations without fuss. Sometimes there’s an explicit deadline like this, but usually your reputation is made of small moments like this one. Did you call the patient back? Did you reply to colleagues’ emails? Did you carry your weight on a paper, or on a committee? Since those are small moments, people decide what they think of you – and ultimately I think you decide what you think of you – in mostly implicit ways. Meaning, you probably never hear back if you’ve lost reputational currency until colleagues refer their patients to someone else or a promotion doesn’t come or someone else gets the plumb teaching assignment.

Here, you are asking fewer than 12 hours before a deadline if you can blow the deadline on a required assignment in order to participate in an optional event. It’s a request I wouldn’t make.

I either execute (99% of the time), or fail to execute but apologize and accept the consequences (0.99%) or something truly unavoidable comes up like a medical illness or a death in the family in which case I fail and apologize but ask for clemency (0.01%). What you are doing is both failing to execute and failing to take responsibility for it, which isn’t one of the options I’d suggest you allow yourself.

I thought about just saying, ‘Sure, no big’ because it’s really not. But then I figured I wouldn’t be holding up my end of the bargain. This is, after all, an essay on your professionalism, and this is a moment in your professionalism.

Hope that is thought-provoking, and that you are having a good time there, and whatever you do, I’m off my soapbox and back to :).

What do you think? Did I make a professionalism mountain out of a logistical molehill? How do you try to support your students’ professional formation?

 

Tim Lahey, MD MMSc, is an HIV and infectious diseases physician and clinical ethicist at Dartmouth-Hitchcock Medical Center and Dartmouth’s Geisel School of Medicine. He is Director of Education at The Dartmouth Institute for Health Policy & Clinical Practice.

 

11 thoughts on “Extension

  1. Dr. Lahey-
    Within this request for “extension,” you “extended” yourself and instead of a simple “no” or even “yes” if you decided to minimize and then move on with your busy day, you took the time to mentor this “threshold moment” of ideally supporting critical reflection on the consequences of such a request (which they may not have fully considered) and we hope, as educators, helped scaffold “transformative learning.” I am thinking about being that patient anxiously awaiting a call back or lying in a hospital bed awaiting a lab result or being that colleague having to cope with someone not carrying their weight on a project, etc etc. I am also thinking about a definition of integrity from Huffpost:: “concept of consistency of actions, values, methods, measures, principles, expectations, and outcomes. In ethics, integrity is regarded as the honesty and truthfulness or accuracy of one’s actions.Let me call out the key words in this definition that are often missed. Consistency. honesty, and truthfulness or accuracy of one’s actions.CONSISTENCY is about being the same regardless of the situation.” https://www.huffingtonpost.com/soyoung-kang/the-true-meaning-of-integ_b_11273420.html CONSISTENCY. DILIGENCE. RESPONSIBILITY. AWARENESS OF POTENTIAL CONSEQUENCES OF ACTIONS OR LACK OF ACTION. AWARENESS of “PROFESSIONAL CURRENCY.” The being AND the doing the work of a doctor. Learning about this in the last required course in medical school? I would hope not. How can we as responsible medical educators start this stuff on day one? With consistency of our own. Without a valid reason for delay, get me the assignment on time. “Small” things aren’t so small. Tough love can be tough. It’s called Education for the becoming of a healthcare professional..

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  2. I am glad you wrote this. It is a helpful suggestion of how to address this type of student request/excuse. Your analysis is dead-on as to why it is not nit-picky.

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  3. This is an excellent example of a teachable moment seized. So much of the value of our educational interactions comes from teaching our students how to think, rather than the content itself. It was likely hard for your student to hear this lesson, but if they can reconcile and integrate the knowledge you’ve given them, they will be better prepared for success in the early stages of their career.

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  4. What did the student say? The concept of a “teachable moment” feels less apt here than the potential to open dialogue and invite a relationship (similar to working with patients). I’m curious to hear how it turned out.

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  5. Great question!

    The student was quite receptive to my feedback and thanked me for taking the time. Later, in what I take as a mark of his sincerity, he volunteered that my feedback might have been better to relay in person. So I got good feedback too.

    More recently, the student said he was glad we were having this de-identified conversation here.

    A friend and colleague, upon reading my original post, raised an interesting related question: should faculty obtain consent from students before publishing anecdotes about educational interactions? An interesting question, I thought. I lean toward “usually not” but what do others think?

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  6. I am an rising chief resident in a Family Medicine residency and we are struggling with similar marks of professional as you clearly identified in you post. In particular, our rising intern class seems to be uniquely challenged by email and beans (our EMR equivalent of in-basket). While residency is an overwhelming busy time, their difficulties seem to surpass those previously seen in our program, albeit a young program. The class is chronologically younger than preceding classes and are, overall, more accustomed to “immediate” forms of electronic communication such as text and Facebook. This is obviously a gross generalization and some members of the group are very appropriate, responding to emails in a timely manner and communicating with patients and support staff but it has moved beyond a frustration and is actually becoming an institutional threat as several residents, for instance, did not apply for Step 3 in a timely manner. We have a graciously patient and amazing program coordinator who spends large portions of her time “chasing us down”. The program has many policies in place with regard to professional expectations but these are rarely applied because our program coordinator and faculty are kindly doling out second (and third, fourth, fifth…) chances. My co-chief and I, however, have begun to wonder that such patience and leniency is actually harming us. As non-resident professionals, we cannot expect to have second chances. I think you have very eloquently (as always) highlighted that professional (and social) perceptions do not allow room for significant revision. We are trying to walk the delicate line between shepherding our co-residents and modeling a “real world” experience, complete with consequences. As we start the next year, I foresee this to be one of the greatest challenges we will face. We are going so far as to set aside an hour during intern orientation to discuss email management and expectations. It actually makes me a bit ill to consider we cannot simply maintain an expectation that our new co-residents will have a base of professional behavior robust enough to drive behavior as simply as checking and responding to email. In the spirit of full disclosure, I am lucky enough to be a graduate of your fantastic MS4 course so perhaps I was privileged in my education and should simply view this as an opportunity to pay-it-forward. That said, I cannot help but wonder at what point we can and should assume professional behavior is a pre-requisite for success and start to hold each other to higher standards in the pursuit of improving lifelong professionalism.

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  7. Dr Lacey-
    I have us the privilege of running a Capstone course for years as well, and have encountered similar requests.

    I appreciate you didn’t take the easy road- as you point out, these requests are certainly easy to accommodate.

    Yet- this is exactly the kind of mistake a student transititiong to a residency could make with a peer, their employer or their patient.

    What I most appreciate is the insight that the student is deferring responsibility to you, the course director, instead of accepting his/her consequences for either doing a less than perfect job or turning in the paper.

    We find the same is true with reports of mistreatment- even with anonymous reporting systems, and end of course evaluations that aggregate student responses over six months, that students would rather “report” to a faculty member something that felt uncomfortable and then have the faculty member try to fix it, rather than make a decision about whether this was uncomfortable but part of learning or egregious enough that it is worth doing something about formally, through mechanisms that are in fact anonymous, but also tracked.

    I think learning that life isn’t that way— nothing is risk free— is important. I wish we weren’t teaching that in Capstone courses, but earlier.

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  8. Spectacular and thought provoking! You made it a teachable moment and you put the responsibility on them! I have struggle with the same issues, honestly I have been perplexed when a student emails me a week after the due date to ask if they can still turn in a received partial credit! As I read the comments and post, students accuse instructors of mistreatment when in reality is the painful consequences of their own decisions.

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  9. Thanks, Dr. Lahey, for a really excellent and thought provoking posting. I think all of us with a little gray hair (ok, a lot of gray hair) lament the professionalism lapses of the millennial generation we teach, and there are some, but perhaps we reflect too little on why this may be the case. For example, I found it interesting that this assignment was part of a “on the way out the door” Professionalism Boot Camp. While now common, this timing may be suboptimal (or at least insufficient) in assessing and promoting professionalism. While this may for your institution be an ideal summative exercise, building on a full 4-year long professionalism curriculum, I lament our collective inability to effectively make professionalism the central tenet of our medical education system, due in large measure to our collective unwillingness to rein in the importance of metrics like the USMLE exams, especially Step 1 (all together now…”Will this be on the Step exam? No? Awesome, then I don’t have to pay attention, as it is of limited importance to getting the residency I want”). The mixed messages that we contribute to, or at best ignore, are not helping our students learn (and more importantly practice) the essential professionalism skills of being a physician.
    I don’t personally believe that this generation of students is necessarily that much worse than previous generations, but rather that we may overlook the shortcomings of previous generations because they are more familiar to us. If I had a dollar for every faculty member who doesn’t turn in grades on time, or fails to grade student assignments in a timely fashion, or doesn’t show up to committee meetings etc, I could probably pay for a whole faculty/student integrated professionalism course. Maybe no one would show up anyway, being too busy doing more important things like meeting their RVU metric or studying for boards.
    Congratulations on your 99% record of executing all of your obligations. I am certain that in my overcommitted life, I have a significantly more disappointing record, perhaps making me a bit sympathetic of the plight of the student. For the record, I think your response to the student was spot on and inspired (and took you a LOT more thought and time than a knee jerk “yes” or “no”) but I think we have a lot more work to do to create the professionalism culture we are looking for.

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    • Thanks for reading Lisa, and also for your incisive reply.

      In retrospect I wish I hadn’t said I execute 99% of the time. I meant I meet my obligations that often, ie I show up when promised or I do what I said I would do, not that I am correct or successful or laudable in some way with that frequency.

      That my phrasing could be read as self-congratulatory is cringeworthy in isolation, but specifically unproductive in this context.

      To me one key part of encouraging professionalism in learners is showing that I’m fallible and working on it daily. We all are. Sometimes the illusion of perfection in physicians can seem unattainable to students, and that may undermine them.

      My well-meant but ultimately imperfect attempt at encouraging professionalism may be just the kind of imperfect human interaction we need. Not some perfect judge-y communication from on high, but one person to another, trying to be good.

      I ended up having a great talk with the student, and learned a lot from him.

      Have a good one!

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