Thursday, March 20, 2014

A Simple Lack of Respect


A different perspective sent in by an intern - what?  We aren't all perfect?  You don't say....   great job, KittySurg.
 



Hi Readers, KittySurg here. I am writing in hope of raising awareness of another issue I see as a great contributor to the high suicide rate in our field. Indeed, performing 4 euthanasias in one day, dealing with Velcro Martha who needs a video of her cat devouring kibble at 2 am to prove the techs aren’t lying, and finding lung mets in your favorite patient can be extremely stressful, but what sends me over the edge at the end of the day is having to deal with some of my asshole superiors and frankly peers, who are so overconfident as to believe that they are always right.

We are a field packed to the brim with type A self-absorbed individuals striving for perfection. The prevailing proclivities are to criticize oneself or criticize others. There is precious little teamwork going on, and support of each other is something we simply don’t have time for.

In the November 15, JAVMA article, “Finding Calm Amid the Chaos,” the consensus from various studies seems to be that those veterinarians transitioning from training to practice seem to be at the greatest risk of depression and suicidal ideation. Entering a new career is always difficult, but working 80-100 hours a week, never seeing family, and living on the poverty line while interest on student debt accrues, can be hellish. If this is coupled with criticism rather than support, one can reach a tippling point, and believe me, many of us have been dangling over the edge.

The fragility of those navigating their first years in practice is a well know fact in Australia and the Netherlands, both of whom have mentor programs that pair newly graduated veterinarians with more experienced colleagues, who help them negotiate their first years in practice and offer general support and advice. I believe that the AVMA should be arranging the same type of mentorship, given the current struggles amid my generation of veterinarians.

Sure, interns and new doctors make mistakes. Constructive criticism is welcome and helpful. I recall giving long-acting insulin IM rather than SQ. The particular criticalist in charge was firm, but nice about my error, much to my great appreciation. She apparently understood that I wasn’t going to learn any more if I’d been able to see the steam blowing out of her ears.

Obviously, constructive criticism for medical mistakes is not the problem I am trying to address. Let’s get back to the topic of unsupportive asshole superiors…

During the first month of my internship, I made what apparently was an insufferable constellation of blunders: I RSVP’d late to the intern dinner, failed to greet a technician in the hall on my first day, wrote in a record that my patient’s anxiety made it difficult to tell if he was painful, and asked Visiting Southern Surgeon if there was a reason not to use a larger holding pin as I watched his 1.6 mm K wire bend under the stress of an overzealous rotation that probably should have been augmented by a cranial closing wedge osteotomy. These mistakes were deemed so serious that they landed me in the office our Very Blonde and Very Crass Hospital Administrator, who has already told our intern class 10 times that she was Business Woman of The Year in our state (after nominating herself 5 years in a row, a detail which she has selectively omitted every time.) VBVC, with her coral lipstick running several millimeters beyond her lip line, asked me why I couldn’t tell the difference between anxiety and pain. “What the hell did you learn in vet school?” she asked, quizzically. “With all due respect, Ma’am,” I learned that animals do not talk.

When I asked Visiting Southern Surgeon about using a larger holding pin, he put down his instruments, looked me in the eye, and told me to “shuuut up.” Later that night when we were finishing up records, he turned to me and told me interns were to be seen and not heard, and that, in one millions years, no question or comment I had during surgery would prove to be useful or correct. “Ahh’m just tryin’ to help you, girl,” he said, with his condescendingly chummy Alabama drawl.

This surgeon’s assumption that the intern is always wrong, and in fact, to blame, has played out perpetually during my year.

Last week, I saw a patient with vestibular disease and a long-term history of otitis externa. I believed that the otitis was a red herring and that the patient had central signs. The attending, Dr. Perfectly Practical disagreed and spent 5 minutes telling me what an idiot I was for missing the obvious—the patient already had otitis, a source of vestibular insult; why would I look elsewhere for an etiology? I was vindicated and (amazingly enough) apologized to when the MRI revealed a giant cerebellar tumor, but I'd spent the morning feeling useless and ignorant.

Then there was the time when I felt my tiny chihuahua patient with a long-term chronic bleed and resultant regenerative anemia (PCV 18) should remain in hospital. Because the source of his chronic bleed had been “fixed,” the attending, Dr. Holier Than Thou Ain’t Never Been Wrong felt he should go home. Yes, the area had been debrided, I thought, but it hadn’t been closed. Little Rembrandt wasn't clinical for his anemia, but I believed he should be in a place that could provide blood transfusion, should he become clinical. Dr. HTT, in so many words, conveyed to me that I had no clinical judgment whatsoever. Yep, time to go work at Starbucks, or better yet, jump off a cliff, I thought. Starbucks won’t even put a dent in my debt. Sure enough, overnight, the little Chihuahua developed tachycardia and bounding pulses. PCV had dropped even further. HTT never apologized—no surprise there.

The next incident involved "Spikey", a cat with paraparesis and pelvic limb ataxia. Spikey needed an MRI, but our MRI couldn't provide appropriate resolution for a creature as small as a cat, so we gave his owners the option of going a few hours away for a stronger MRI or staying here at the hospital for CT/myelogram. Our neurologist had left the practice, and trying not to lose our neuro clientele, we had been given scripts by our Very Blonde and Very Crass Hospital Administrator in response to client questions. One such script stated that all of our surgeons are proficient in CT, myelogram, MRI, and all neurological conditions. Sure Thing, Blondy.

Of course, in spite of these scripts, our Interviewed in Flip Flops Saturday Surgeon from the Virgin Islands had not yet learned to use CT. He'd been here several months, but couldn’t manage to drag his ass to the hospital on a day off (he has 3 every week) to learn how to operate it. The radiologist (who I actually like and respect) was able to operate it, and was slated to be present on the morning my patient needed the CT. All was a go. No one said anything to the contrary in rounds that morning, and Flip Flops had never said that his morning appointments would preclude fitting this in. He said he might have to call in the head surgeon if he got stuck, but this was a "might," and I'd gotten permission from the owners to do the imaging the following day if things got too booked.

This said, I was quite surprised late that morning to learn that Dr. Flip Flops had decided that CT/myelo was out of the question for several different conflicting reasons provided to me by Dr. HTT and later, Dr. Flip Flops himself. I was now supposed to lie to the client and say we felt the cat needed an MRI. I'd had a decent relationship with the client, but he was incensed when I told him that, out of the blue, we'd decided CT/myelogram was going to be useless. Wooden Q Tip (not to be confused with the plastic, pliable variety), the head surgeon, read my client communication (and from home, nonetheless). He grew frustrated with Dr. Flip Flops, and offered to come in and do the CT/myelo himself. Great! Time for the intern to change the story on the client again. Frankly, I felt the clients should just hit up the MRI at the other hospital and give them the business, because we couldn't get our act together and worse, we had lied about it.

The confusion and frustration led to displacement of blame. Where? To the Scapegoat Intern. Where else? Dr. Flip Flops told Dr. Wooden Q Tip that he'd asked me to arrange for him to be there to help run the CT, etc. etc, and I got an earful from everyone involved. Q Tip screamed at me over the phone, “You and everyone else there are useless; completely useless, “ he said. Flip Flops told me I was a waste of his time, and Very Blonde and Very Crass marched downstairs from her corner office and took the case away from me. “Flip Flops and HTT will be handling the case from here on out, she said.” She was nice about it, so I have reason to believe she saw that I was right, but in a pinch, had to apologize to the clients and blame Scapegoat Intern, who didn't know the ropes; Spikey’s owners later came to visit him in the hospital and looked right through me, as if never having met me. After his CT, Spikey became intractably fractious and impossible to handle. I wished so hard he’d bite the shit out of Drs. Q Tip and Flip Flops, but sadly, the docs never saw the need to actually handle him and give him the chance.

I just finished another 100 hour week, much of which was spent dealing with Velcro Martha, who didn’t believe her cat was eating in our hospital. Three nights ago, I was in the exam room with her, trying to explain every alteration in her cat’s fluid rate and why, if he was fluid-overloaded, we weren’t even bothering to exercise him. Worse, I had to talk over her 100 year-old mother, who was alternately slurping her Ensure, farting, and chanting “necky necky, rubby rubby,” while petting the poor cat, who like me, seemed stifled by Grandma’s fart cloud.

The next morning, on my day off, I got a call from a client and friend who asked me to euthanize her diabetic dog, whose blood glucose had grown increasingly difficult to control. In between sobs, she told me the dog was completely distraught, pawing at the water bowl and vomiting. It was 6:45 am when she called. She said she lived 30 minutes away and that it would take her another 30 mins to get ready and get the dog into the car.

I got to the clinic at 7:45, euthanized the dog, and was feeling sad about the whole thing, but at the same time, I had a moment of feeling useful—a  very short moment. As I was leaving, Patronizing Good Ole Boy ER doc/New Dad approached: “If you meet a client here, you have to be here on time,” he said, sneering. The client had arrived at 7:20 and told Dr. PGOB Daddio that they were supposed to meet me at 6:30. I explained to him that the client was distraught, and had surely had been confused. He rolled his eyes as if to say “whatever, dumb ass”. “Furthermore,” he said, blood pressure should have been taken earlier on your renal failure cat.

I have a surgical internship next year, but unfortunately the ending date of my rotating internship and the starting date of my surgical internship are June 29 and July 1, respectively, and also unfortunately, they are on opposite coasts. Neither program will budge. I can feel it: next year is going to be even better.

14 comments:

  1. Stories like this are the reason I elected not to do an internship. I know there are good ones out there, but I decided my time was better spent finding a few good mentors in private practice and spending my days "off" following them around for the first year. For me, it was the right decision, but I know not everyone in the private sector is so lucky. I'm sorry you work with assholes that feel the need to distract themselves from their own insecurities by bashing the people they are supposed to be mentoring. Hang in there.

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  2. I hate to tell you this, but a lot of practices treat their associate veterinarians like this too. I've experienced it myself and heard it from other associates as well. This is NOT just an intern thing - only real difference is that you make a bit more money while you're treated like dirt.

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    1. Just left a practice like that. It's true, and the sad thing was, I wasn't even learning much.

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  3. just so you know, this isn't isolated to the veterinarian world.. I've run into my share of managers that act the exact same way.

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  4. I was reading this and had to keep reminding myself that you're a veterinarian, not a human doctor, because, damn, this sounds familiar. I'm not even a physician, but I've worked in medicine 25 years and have seen this type of treatment.

    *sigh* Why must we continually eat our young?

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  5. I'm too old & grumpy to put up with that kind of crappy treatment from anyone.

    I try to treat everyone with proper respect.

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  6. Didn't do an internship but this sounds exactly like my first job as an associate. Since that unpleasant year I've met half a dozen other veterinarians who also spent their first years at that same practice and despite differences in age, gender, clinical interests, skill sets, alma maters, and personality types, they all tell strikingly similar tales. It wasn't me, much as the wife of the practice owner insisted after I told them I was leaving at the end of the contract year.

    It's only going to get worse. Practices who can't afford to pay associates appropriately simply cut the pay, call it an "internship" and don't much care about the built-in employee turnover, because it's an "internship". Just this week I've heard about four different interns from three different practices who all left mid-year. Gee, I wonder why that might be? It's also common for new graduates to serve multiple internships because there aren't enough residencies to absorb all those interns for advanced training (Yet. Give the schools time...) . Some of the more prestigious internships won't accept interns who haven't yet had at least a year's experience as an intern (really). This lack of residencies is a Very Good Thing, because there is not sufficient demand in veterinary medicine to justify more boarded specialists. Clients already don't want to pay the prices set by generalists for routine care. I already know two boarded specialists working in low-cost, high volume practices and of another working for a corporate chain. What a mess.

    Hey, AVMA, how 'bout some more stringent standards for "internships". Unfortunately, there isn't much anyone can do about practice owners who treat new graduate associates poorly, but the veterinary community can at least demand more truth in advertising.

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  7. Huh. You probably did your internship at the same place I did my residency. Oh, wait, mine was in the midwest and was large animal. Never mind. I wish this was an isolated problem but it is so painfully obviously not. My resident advisers made me go to counseling (I'm not sure what that was supposed to help) and the counselor told me I should be suicidal for all they put me through. I wasn't, I was just pissed, but I'm a touch b!tch so I see how most people could be driven to it.
    I am boarded, but I am not a dues-paying member of my specialty, nor will I support or attend conferences associated with them in any way. Neither will I support the institution at which I did my residency in any way, even peripherally. It might seem like cutting off my nose to spite my face but I'm content in my practice and my life, and I can't support a system with such institutionalized abuse. I tried to discuss my experiences with the supervising specialty, because I truly believe the institution at which I trained SHOULD NOT be allowed to train residents but, in typical "professional" manner, everyone I talked to declined to get involved.
    Inspired by VBB and Dr Grumpy, I'm starting my own blog. It will be mostly client interactions, etc but one aspect I plan to write about is the academic setting - internships, residencies, the "truth" behind the ivory tower. It may not do any good but I think future potential interns and residents have a right to know the truth about the torture they're in for. And its not everywhere - my internship was lovely which made the pain of the residency that much more acute.
    My new blog is at awesomecritterclinic.blogspot.com - visit and spread the word. I've only posted an intro post at this point and am hoping to get some more content up soon.
    PS - I did not just comment to promote my blog. I commented because I feel your pain in so many ways. I was finally motivated to create an anonymous account so that I could, like you, help spread the word about the truth. Stay strong friend.

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  8. Kind of like questioning why veterinary schools are making the completely -optional- rabies vaccine mandatory for students for continued enrollment in their programs, I've been asking some serious questions for a while now and apparently getting beamed into the Cone of Silence for my troubles. But I'll ask it again here. Maybe the OP (or Jenna) will see it and comment more in-depth about this relatively new phenomenon no one is talking about.

    Why are there now internships which require internships? What the eff has happened to internships and residencies since the last time I seriously looked at them, in 2002?? I'm not talking about young veterinarians doing multiple internships while waiting for a residency to open up; I'm talking about an internship clearly stating a previous internship is requisite for consideration. Is this what we're becoming as a "profession"?

    I won't even get into the fact CSU offered a surgical residency with ZERO pay (which I sent in to here with zero response back on it). In fact, whoever applied for it would have to pay. Mark my words; it wasn't just because of a "lack of funding" for this year; they're testing the waters.

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    1. Internship programs don't generally state "previous internship required" explicitly, but I had been hearing this from disheartened new grads I encountered at meetings. Then, at a meeting two years ago, a dean of students proudly declared to me that their applicant pool for interns was so deep all of their interns had already completed at least one internship. They weren't bothering to consider graduates right out of school. I looked at the intern bios on their website and the dean wasn't lying.

      Meanwhile, there are veterinary residencies at prestigious programs currently paying <$20K/year. It's commonplace to see internships advertised at $25K/year or less. Internships and residencies for physicians pay at least double that. It actually doesn't shock me to hear about a surgical residency paying nothing. I think new graduates accept these terms because the alternatives are either unemployment or accepting a job at an unsatisfactory practice (toxic environment, low-quality medicine or both).

      Meanwhile, this spring the owner of a specialty practice was advertising an associate position paying an advertised salary of $30K. I know another new grad with huge debt who accepted an "internship" in a practice almost exactly like mine before I left practice (similar caseload and experience level of owner veterinarian but not board-certified) paying $25K with no benefits. State jobs aren't the answer, either; one of my friends with 10+ years' experience was just hired for a rare full-time state veterinary job paying $50K. Worst of all, it has become more common to see very recent graduates or even new graduates setting up practice on their own because they either can't find satisfactory jobs where they want to live or figure if the pay is abysmal they might as well go into business for themselves. This does not bode well for the future of veterinary medicine.

      Welcome to this wonderful profession, kids.

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    2. They are explicitly stating prior internship experience on internships posted to virmp now. I assure you, I didn't pull this little 'factoid' out of my ass. :) Admittedly, it seems more common for listings other than those for "general" rotating internships. The ones for emergency med/surgery internships are good examples of this phenomenon.

      I did not see salaries as low as you stated. What I did read was in the 30-38k (as low as 25k with housing) range for internships, and I was looking across the spectrum (e.g., ag animal, dairy, SA emergency, SA surgery, other SA specialties) out of curiosity . At least approximately 32-42k progressive pay for the spectrum of residencies (possibly both lower and higher; was not the focus when on there). All with varying degrees of benefits, but seemed to consistently include some sort of health insurance, liability, state license, and CE.

      It's a crying shame to hear "..it doesn't shock me...". You should be shocked. In fact, everyone who learns of the test position should freaking rage. Yet, quite disappointingly, we do not and very likely will not. It'll certainly be interesting to see if in another decade both internships and residencies become for-fee if new graduates bite out of desperation and willingly become the mules to be saddled with the additional debt. I'm betting now academia and private practices alike try their damnedest to make it so.

      As for those striking out on their own? I don't know if it really *is* bad for the profession. In fact, it may even be good for it instead of relying on a "mentor system" which is so grossly broken. New graduates doing so have also revived housecall and expanded home euthanasia niches nicely along the way. Not to mention I've seen doctors with only a year or two under their belt, on their own, practicing far better medicine than my first boss did with 16 years under his at the time of my hire.

      Regardless, unfortunately, I do agree with your final assessment. :\

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    3. One of my friends just finished a residency at one of the most prestigious schools in the country and was paid $19K/year. Seriously horrifying. That is why it doesn't shock me to hear CSU is offering an internship for no pay. I'm saddened, but not particularly surprised. Veterinary schools have made it clear via their actions over the last few years that they're in the business of making money by admitting and graduating as many students as they can cram into their facilities, and who cares what happens to those graduates?

      As for new graduates striking out on their own: it probably depends upon the new graduate and the mentor. Professional isolation is never a good thing, particularly early in a veterinarian's career. Those new graduates might be better veterinarians than your first boss was, but that sounds like a rather low standard. As for home euthanasia services, it's a niche, but not something most veterinarians would want to do full-time, certainly not right out of school.

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  9. I don't know whether to say I'm relieved or appalled by this post... I endured two internships because I am so passionately in love with surgery and still failed to match for a residency. One was a private specialty practice the other a university. As I left the first I said it couldn't possibly get worse yet I found myself descending into a deeper level of hell. I was constantly in trouble for asking questions because I wanted to learn that were perceived as questioning the so-called superiors ability or knowledge and, at least once, my question was ridiculed simply because the surgeon did not know the answer but was unwilling to admit that. I could relate story after story akin to KittySurg's accounts. I thought that I must have just had crappy luck in my choices but obviously this is a more widespread problem. And, as commented by others, I've had the same types of experiences in my other jobs as an associate. I've never been the type of person who believed myself to never make a mistake and always be right but the end result of these experiences is that I can intellectually tell you the things I'm good at in vetmed but I constantly question myself and have very little confidence. Amongst other things, one of the worst scenarios was between me and a resident who I had known when she was an intern and I a fourth year student on clinics. I had to speak to the senior clinician during rounds to stop her from starting IV fluids on a congestive heart failure dog with severe pulmonary edema because she refused to listen to me, being a lowly student. Who knew that she would remember and exact deliberate revenge by lying about me a few years later when she was the senior resident? Like KittySurg, my internships overlapped and I had to jump through ridiculous hoops to make it happen - all the while being told that my decision to pursue learning was supported and while an internmate affectionately called golden balls because he was the favorite was allowed to leave early while making no compensation. All that said, I am now in the process of seriously exploring other career options outside of vetmed. Huge debtload still to pay for a degree I'm about ready to toss!!

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  10. it starts even earlier than the internships and residences, I'm a final year vet who is supposed to be learning every day on rotations and instead we're running around like crazy people trying not to caught between the interns, residents, and clinicians fights not to mention the departmental squabbles (it's anesthesia's fault, no it's radiology, no it's surgery - fine we'll just blame the students!).

    A friend of mine just failed a rotation for DARING to ask the intern (a girl we were out drinking with no less than 18 months ago) a question because she had recently read an article that stated something different to what she was teaching a group of 20 students. So my friend, thinking, if it was her she would want to actually know the right answer, went and looked up the paper and brought it to the intern. She was publicly ridiculed, the paper was tossed out and the intern is still teaching the wrong information and my friend has to repeat the rotation with her ... oh and do you want to know what everyone's response to my friend is: "What! You never look Medusa in the face let alone attempt to correct her!" It's insane. Things have got to change!

    Another problem I have with all of this is a lot of the time recent grads and interns and residents are more up to date on the latest research and current practices because we've just been taught them ... I can't understand why senior clinicians wouldn't want to use this knowledge we're literally bursting with, instead they just seem to beat the joy out of us ... it's literally a crying shame. We're obviously going to make stupid mistakes and need time to gain experience but most of us don't ask questions to be assholes, we're trying to learn and solidify our knowledge etc.

    I will add that I was at business conference a few weeks ago and in the UK they're starting a new mentoring/recent grad monitoring program that looks promising so I hope that goes well and in the US the AAHA & VetPartners have this mentorship toolkit package thing but I don't have any decent info on it. I hope to god I don't find myself in one of these situations next year, my already fragile psyche is not going to take it well (that or I'm going to get my ass fired for talking back).

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