If you have to choose between the two, it is better to be feared than loved, for fear preserves you by a dread of punishment, which never fails.
Machiavelli, The Prince
"So why didn't you order potassium in the IV?"
Coming from a medical student, the question was innocent enough. For us three clinical clerks, it was day one of the surgical rotation. Keen and eager, we had just met our preceptor as he exited the OR to write postoperative orders. Now a curious and fertile young mind was seeking a little knowledge - some enlightenment from the master. It was the perfect moment to teach. Or to destroy.
"Don't you know anything about electrolytes?!" snarled the surgeon. There followed a flurry of questions, each more difficult than the last, a rapid-fire grilling about intra- and extracellular anions and cations, cell physiology and renal function. Now totally rattled, the student could only respond, "I don't know, I don't know" until, humiliated in front of her peers, she broke down and began to cry. The surgeon sneered and stomped off without a backward glance.
None of us ever asked him a question again.
Instructors in medical schools and residency programs usually have no formal training in education; anyone who has made it through the system is deemed capable of teaching. As a result, the quality of teaching in our academic centres varies tremendously. While some preceptors are exemplary, others are mediocre, inept or just plain uninterested.
And a few are bullies who use their position in the medical hierarchy to intimidate and browbeat. The same feeble pretexts for this churlish behaviour surface time and again: "I'm doing this for your own good," or "That's the way I was treated when I was a resident." Weak excuses that fail to cover what is really an abuse of power.
A sure sign of a bully is the habit of making an enormous commotion over a minor incident. One of my more memorable moments as a surgical resident involved a bowl of soup. In our last case of the morning the surgeon scrubbed out early and strolled away for a leisurely lunch. In the meantime, I closed the incision, dressed the wound, waited for the patient to wake up, helped transfer him to a stretcher, jotted down an operative note, wrote the post-op orders, dictated the case, and answered some questions from a medical student. I then grabbed a bowl of soup from the food cart in the OR lounge. I had just raised the spoon to my mouth when the intercom crackled: our next patient was in the operating room. The well-fed surgeon, hearing the announcement and seeing me with spoon in hand, went ballistic. An observer would have thought that I had been caught red-handed stealing nuclear weapons secrets. Figure 1
"How dare you," he spluttered, so choked with rage that he could scarcely enunciate. "How dare you sit there and eat soup while my patient is in the room? What kind of resident are you? Where are your priorities?" And on it went. Apparently the surgeon believed that public chastisement was an effective teaching tool. Dire predictions of my failing career continued at full volume, in easy earshot of others, while I put down the spoon and scrubbed up.
Bullies may create the illusion that technical prowess compensates for personality disorders. Recently I ran into a family doctor who was a medical student on service when I was a resident. I asked him about his most vivid memory from his surgical rotation. Without hesitation, he replied: "There was this one surgeon, he was all over us all the time, even at three in the morning. Nothing we did satisfied him. And he would belittle the OR nurses until they ran out of the room crying." Then, almost apologetically, he added, "But he was a helluva surgeon."
A physician can possess great operative dexterity or encyclopedic knowledge but still be a failure as a teacher and an overall liability. In The Dilbert Principle, Scott Adams advises that nothing can "drain the life-force" out of an organization like the few bullies who are bent on making life hard for others. These employees may have important skills, Adams writes, but the trade-off is never worth it. [1]
Now that the formal portion of my training is complete, I look back on the experience with many fond memories. I had scores of preceptors throughout medical school, internship, residency and fellowship who were fair and had a genuine interest in helping students succeed. An unfortunate few failed to recognize that residents are mature, accomplished adults, not raw recruits in a Marine boot camp. I look forward to the day when this type of behaviour, which is not tolerated in most other workplaces, will be out of favour in our medical teaching institutions.
Robert Patterson, MD
References
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