notes

Failure

·5min

It is disheartening to put immense effort into something, only to be told it was not enough—that you should have worked harder—and to feel that a single negative incident may affect your future prospects.

That is what I felt when I received a negative evaluation for a rotation I had worked hard on. I had otherwise performed well, only to collapse under pressure during the final hour of the final day, amid extraneous factors and while working with a staff physician with whom I had no prior interaction. Their opinion subsequently became the bulk of my evaluation.

Initially, I was confused and frustrated. Looking back, I am clearer about my view:

  1. I still feel my perspective holds value. The evaluation reflects a few days’ worth of data at best, and likely only a few hours given the circumstances above, while most of my rotation was spent with other staff physicians and residents on different services. Although there may not be a more practical way to evaluate trainees in the surgical environment, I believe evaluations should be treated as snapshots rather than the full story of a candidate’s journey. Given the number of evaluations each trainee receives, I think they often are treated that way. Yet in a competitive field with numerous applicants, selection can turn on the smallest factors, and these little weeds can play an outsized part. Time will tell whether that is the case.
  2. An opportunity for growth. Regardless of the situation, you are expected to perform in the clinical environment because your actions can affect life-or-death decisions. I recognize that having a defined structure to fall back on when collecting and presenting information will serve me well, allowing me to operate on autopilot when my brain has little more to give.
  3. A reorientation in clinical interest. The staff in a field can tell you a lot about the people it attracts and how it treats those with less prestige. Although a single negative experience is not a well-formed reflection of a field, just as applicants are judged by the tiniest weeds, so too am I forced to judge a field from a limited experience. Exposure to each field during a rotation is brief, yet we must make a rapid decision about what we want to learn and live by for the rest of our careers. We have to make calls without the sample size to back them up.

Ultimately, I have determined that this is not a time to be carried away by the current. We all receive negative feedback that can feel incongruent with our perceived performance and effort, but allowing it to dictate the next steps of our journey would be a disservice to ourselves and risk making that feedback true. Continued effort and improvement will keep a weed small, shaded, and slowly smothered by the garden of skills we grow.

Presenting

Skeleton of Consults/Presentations
1. ID: Patient A is a [stable]/[unstable] # yr old M/F with a PMHx/PSHx of *** [who is here for]/[we were consulted for] ***.
2. HPI: Her symptoms started *** ... (if there is pain, characterize quantity, quality, aggravating and alleviating factors, associated symptoms, and timeline)
3. ROS
4. Background (optional): Most important are allergies, medications, FHx, and SHx
5. Course in hospital: Present what has already been done in terms of treatment
6. Results: Objective data from the physical exam, labs, imaging, and procedures. Be consistent in your presentation order to avoid missing findings.
7. Management: Present your differential, recommended workup, and management plan. Repeat for each problem.

Tips

  • Steps 5-7 are best done per problem for better organization
  • The above format closely aligns with SBAR and is useful for organizing presentations for new patients, general rounding, and consults. Every individual point can be broken down into SBAR.
    • If your problem-based presentations lack structure, break each problem down into: 1) prior patient status, 2) what was done, 3) what was found and your interpretation, and 4) next steps.
    • Example for a “solved” problem: 1) She reported diffuse abdominal pain that became more stabbing and focal, migrated to the right lower quadrant, and was associated with nausea and vomiting. 2) She was evaluated with serial vital signs, abdominal examinations, a CBC, and an ultrasound. 3) Findings included McBurney point tenderness, leukocytosis, and an enlarged, edematous appendix with an appendicolith, consistent with acute appendicitis. 4) I would seek surgical consultation and discuss laparoscopic appendectomy. The 2025 WSES guidelines describe appendectomy as the standard surgical approach when surgery is indicated and note that selected patients with uncomplicated appendicitis may be candidates for nonoperative management with antibiotics.
    • Bonus: Prepare the other findings you would expect from the leading diagnosis and differentials across the history, physical exam, and investigations. These become your pertinent negatives and teaching material. For acute appendicitis, the patient endorsed the classic migration of pain, nausea, and vomiting but denied fever or anorexia. Ectopic pregnancy is less likely given no recent sexual activity, a negative β-hCG, and ultrasound findings supporting appendicitis.
  • When presenting to a new staff member, always collect and present as much information as possible regardless of how clear the diagnosis is and how irrelevant the information appears. You can become more concise as you learn the staff’s preferences and as you build trust/rapport.
  • You will be pimped. At this stage of training, most staff are interested in your management above all else, assuming you were thorough in your presentation. Prepare your differential and be ready to defend your shortlist by knowing which findings you would expect on history, physical exam, and investigations for each diagnosis. This will also help guide your workup and management plan.
  • No problem is too small in a teaching hospital. Address every issue. At worst you will not do active management for it. But you will be prepared for it, and show attention to detail by reviewing it.
  • Review your imaging findings, not just the impressions. I have had way more staff who like to pimp on the findings reported that led to the radiologist’s interpretation, rather than on the visual image itself.