A Letter to an Attending

Who do You Think You Are?

Dear Sir or Madame,

I am exceedingly glad to be done with the rotation. I have been a resident for almost two years and that month was perhaps the worst experience of my medical career. You made what should have been a moderately unpleasant experience which is what we expect on rotations in your specialty into an almost unendurable ordeal which no one in any other career except ours would tolerate with as much good humor as I did.

I have most certainly quit jobs for less, and it is only the iron grip on my gonads enjoyed by the hospital that kept me from telling you to “admit your own goddamn patients.”

Now, the fact that you had it harder when you were a resident, something you pointed out on every possible occasion, is completely irrelevant to me. I don’t care. Let’s just assume I am a pussy and leave it at that. I’m not about to change my ways now just to please you. You’re not my mother. You’re not my father. Hell, you’re not even in my chain of command and your bad evaluation is going to sit in my file doing nothing until, one day, some alien archeologist sifting through the sterile rubble of our planet deciphers it and comments to his collegues that you were a real horse’s ass.

You accused me of being unenthusiastic and on this charge I am completely guilty. I am interested in most aspects of medicine including your specialty but if you expected me to clap my hands and squeal for joy at 4AM when confronted with the twelfth admission of the night it is no wonder you were disappointed. As even you grudingly admitted that I did my job and everything asked of me, I don’t know what else you expected except for me to kiss your ass and pretend I live for every-third-night call

I was also less than thrilled to be pimped over the phone in the early morning hours when all I was trying to do was admit an uncomplicated patient. If you want something other than what I ordered for the patient have the goodness to tell me as I am not a mind-reader. And as I am usually physically ill at that time in the morning from fatigue, dehydration, caffeine, and lack of sleep, just tell me which of many formulas you would prefer for me to use to calculate creatinine clearance and I will use it. Don’t make me decide and then ask me to justify my decision.

Did I mention it was 4AM? I don’t care. We weren’t even talking about a renal patient. On every occasion when we spent an hour on the phone picking the nits off of nits I had a board full of admissions from the other services I was covering and a couple of pagers that that would not stop beeping. If I am to sit under a tree in the agora soaking in your wisdom in the socratic manner than call off the dogs from the other services. We don’t have time. I would have also liked to have layed down for an hour or two after I cleared the board and you were seriously slowing me down.

Additionally, if you were reading the lab values off of your computer at home, why did you have me repeat them to you over the phone? This is just sadism on your part and why, after I found out, I refused to do it. Who do you think you are, anyways? You don’t pay my measly salary, I have sworn no oath to be your little scut whore, I’m about ten years older than you, and there is absolutely nothing in it for me to repeat numbers to you over the phone. And your weasel-like excuse that it was good practice make no sense. Practice for what? My eight-year-old can read numbers over the phone. I reviewed the lab values and the fact that you seemed to think I had not belies the trust you purported to have in me as a fellow physician.

I also didn’t appreciate your patronizing attitude and how you called me “Doctor” in an ironic and insulting manner. On one hand you insisted that you expected a lot out of me (“doctor”) and that you expected me to think independently (“doctor). On the other hand you micromanaged every single decision to the point that when I asked you why you didn’t just come in yourself and eliminate the middleman, I was being completely serious. The premise that you were treating me like a fellow physician was ridiculous. If you treated your colleagues like that I’d be surprised. And as I am working for about a tenth of what you make on an hourly basis, well, the reality is that you treated me and every other resident who has worked with you as low-wage sweat shop labor.

Not to mention that If I was a valued colleague you wouldn’t have been so snotty when I gave you my opinion.

That’s another thing, if you don’t want my opinion, don’t ask for it and don’t get all bent out of shape when I give it to you. In my opinion, my job on the rotation was to provide cheap clerical labor for which you otherwise would have had to pay somebody a decent salary. I think I’m on the money with that opinion, at least from my point of view. If you don’t agree, well, you don’t agree and the fact that I didn’t apologize for my opinion should tell you something.

In the end, I think that’s what really pissed you off. When you called me on the phone at the end of the rotation to express your displeasure with me and my attitude you were probably expecting the usual obseqiousness to which you are accustomed and some sort of apology with a promise to do better.

But you don’t own me. I did my job even though I don’t like you and I’ll be damned if I’ll apologize to make you feel better about your personal control issues. You do your thing, I’ll do mine, and I will never have to work for you or with you again.


P. Bear, MD

41 thoughts on “A Letter to an Attending

  1. very funny as usual! I really hope that if I have a hard residency (i’m starting med school this fall so it will be a while), that it will only make me want to not make all the same stupid, rude behaviors as you described. Congrats on being done with her!

  2. The problem is that my cohort and those before us have been conditioned to take the abuse without complaint. I hope that by the time you are a resident your cohort will not be as big a bunch of wimps as we have been been.

  3. Best, absolutely The Best blog site on the web Panda. Keep up the good work!

    The pimping at 4am is always a classic, and as in your story- it is always creatinine clearance controversies- never fail. I don’t know why people love that so much.

    Academic internists; who are you and what do you do? I honestly want to know.

  4. well said, i would have to agree with ProtonDense about the academic internist. who in their right mind would even think of a pimp question at 4 am.

    my philosophy is
    1. please don’t call me early in the AM if it can wait til i come to rounds in the morning
    2. “pimping” or as i call it, asking questions to check if you bothered reading, is only for those specific times were you can see them coming. preop and post op conference, occasionally in clinic, and in the OR. my feeling is the questions asked should be BOLDFACE answers and should be to lead you in the direction of learning for that particular disease.
    3. appreciate that everyone is working hard especially the people on call, and give them a friggin break.
    4. the attending only knows as much as s/he knows and has a unfair advantage when asking any question, so don’t get on you high horse about not knowing stupid esoteric shit.

    and there is probably more but i can’t think of it. my take on the who attending thing is that we are all human and we should treat other as human beings and not think we are some kind of GOD (we are not gods and are frequently wrong). and that’s all i got to say about that.

    happy easter everyone.

  5. Now look, I am the essence of good manners and politeness and people marvel at my stability, my good humor, and my tolerance for all manner of things.

    But that’s just self-discipline.

    In no way do I go out of my way to upset anybody but this particular attending had a huge chip on the shoulder and resented mightily my lack of enthusiasm, taking it as a personal affront when in reality, I was just unenthusiastic for Q3 call.

    That’s the thing people don’t get about me and this blog. I don’t dislike medicine, I merely dislike working like a tortugan sugar plantation slave for low wages and I don’t see where it is written and how it came to pass that medical training requires sleep deprivation.

    I am working on an article, to which I am applying more thought than I usually do, about how I would structure residency training and one important concept is for the hospital to reckognize that medicine has become, at least at big academic and charity centers, a 24-hour-per-day business and they need to structure everybody’s schedules accordingly and stop pretending that “work” is “call.”

    In other words, if everything is a goddamn emergency (consults, admissions, and the like), then structure the other medical specialty training programs how we do it in EM, that is, shift work with a protected didactic block every week.

  6. Also, creatinine clearance is important. I don’t want you folks who are not yet in the thick of it to think otherwise. Many drugs are renally cleared and need to be adjusted.

    Here’s a PS:

    Dear Sir or Madame,

    I selected the particular antibiotic empirically based on the guidelines in my EMRA antibiotic guide which most Emergency Physicians use. While I have a Sanford guide, to tell you the truth it hurts my eyes looking at that microscopic font and, amazingly enough, the EMRA guide follows Sanford exactly as far as empirical treatment. Once we isolate a bug we can get as jiggy with it as you want but you know very well you’re going to chicken out and consult Infectious Diseases. I also didn’t appreciate your comment that the EMRA guide was for dumb ER physicians.

    So it was amazing that after arguing for then minutes for every patient, we eventually came around to the exact same antibiotic and dose I has selected in thirty seconds from the EMRA guide. If you wanted something different, you could have just said so instead of involving me in your internal debate.

  7. Please respect my anonymity as I have yours.

    Have you not enjoyed any part of your EM residency (or your previous residency)? I recognize that its hard, but surely there must be something beneficial. 5,000 + EM Residents suffer this fate each year and plenty come through on the other side grateful and respectful of the training they have recieved. Escpecially since it is the only pathway to Board Certification in EM. I love your blog…just looking for something positive about your colleagues, training, improved skill set, positive patient outcomes….something to tell me you enjoy what you do

  8. I repeat: There is nothing I enjoy about working q3 or q4 call for taco-jockey wages. I like shift work like we do in the ED but other than that, it all blows including every non-EM rotation of which I have done (since I repeated intern year) about 17 out of the last 20 months.  You are still getting too metaphysical with it it.  It is a pay and hours issue with me.  I hate any job when I am tired and physically ill which I am on almost every call night.

    As for being “grateful,” why should I be grateful to get worked like a slave on off-service rotations by people who treat me and other residents with profound carelessness? Pay me more and I’ll be more grateful.

    And it is difficult to be respectful of a lot of the training when it is so bogus. This includes almost every surgery rotation I have done where I was nothing but a paperwork scut monkey. Even the surgery interns will tell you that a lot of their training is BS.

    Also, there is nothing to enjoy or respect in someone who treats you like dirt like the anonymous attending to whom this fictitious letter was not sent.  That’s kind of the point.  We need to rise above the attitude that is common in residency training that abuse and sleep deprivation are necessary for training.  I don’t even know how this syllogism became the reality because it is insane.  Totally crazy. 

    I enjoyed nothing about my previous residency.  That’s why I switched.  I like my current program, I like all of our attendings who treat us with respect, and I like my profane and irreverant colleagues. 

    Why would I not respect your anonymity?

  9. I couldn’t agree with you more about the useless mental masturbation (4am pimping, hour-long lectures by the attending on the differential for hypokalemia, etc) that afflicts the field of internal medicine.

  10. Sheesh! This is what I have to look forward to? As a former infantry medic it appears I’m not really looking forward to such garbage. Why does academic medicine have such a ‘tude?

  11. Older than average residents are always going to be problematic for academic training programs. Their structure makes it difficult for them to benefit from your added life experience – you still start at the bottom, just like everyone else. And your added life experience makes it difficult for you to tolerate their demands – if I’d had young children during residency, I’d certainly have felt the same way as you do. During my training, I was excited to get each meager paycheck since it was the most I had ever earned up to that point. From your perspective, things are different, obviously.

    But you and those like you bring a lot to the table, and there should be some way to make it work better for everyone concerned. I can’t wait to read your suggestions.

  12. I agree the attending might have had a problem with your being 10 years older and very assertive… Could have made him/her feel insecure. Know the type. Be glad it’s over.

  13. I usually don’t offer caveats but as this post seems to have generated a lot of angst (and you should see my private email), not every attending of service is as bad as this. It’s a crappy systems but not everything about it is crappy. I have had some rotations where education was stressed, I have had plenty of decent attendings, and I have had a lot of fun…just not on rotations where I am on q4 or worse call and treated like cheap labor.

  14. Panda – I look forward to reading about your thoughts on how to structure residency on the shift system, in particular the surgical fields. One question – if residents will do 10-12 hr shifts like in EM, won’t that mean some loss of coverage? Won’t it have to be made up by getting more residents?

  15. Well, what is the purpose of residents? The Man swears it is for education, that we are not really necessary, and are in fact a drag on productivity. If that’s the case, what does it matter?

    My point is that it makes no sense to have 90 percent of the residents at the hospital for only forty percent of the productive day. Better to spread them out so call (except for real call which is supposed to be a system where the doctor is only bothered for emergencies)is not necessary.

    I don’t mean to sound cavalier but the hospital’s staffing decisions are not my problem and I can’t think of any other job where the employees are held personally responsible for their employers lack of foresight and ability to schedule work realitically.

  16. Actually, a shift system would give better coverage. Additionally, if some of those residency programs in unpopular specialties payed their residents a little better, who knows if programs like Family Practice and Internal Medicine wouldn’t become more popular.

    But like I always say, the real trouble is that as long as there are pre-meds willing to sell their grandmother’s organs to get into medical school, there will always be a supply of cheap, abundant labor for the hospitals. I have no doubt that most medical students would take a pay cut with no complaints.

    I know this, you know it, and the hospital knows it which is why there is no pressure to increase salaries. Supply and demand, in other words. If they can’t get an American resident they can always get an FMG who, because of the difficulty of getting established in the United States, is even more willing to take the abuse. Can’t blame ’em but there it is.

    The only way to put pressure on the hospital to increase salaries is to force another decrease in work hours, this time by legislation that carries the full force of law,but this time making it just a decrease in the number of uncompensated hours. In other words, mandate overtime pay for any time over, say, fifty hours.

    The residency training system is ridiculous.

  17. And, if the hospital cannot figure out how to cover their responsibilities by having their residents work five 12-hour shifts per week then they need to hire better managers. The way to do this and to maintain education is to work shifts with a protected didactic block every week.

    I realize that Internal Medicie, for example, wouldn’t want to give up their morning reports and noon conferences but if you think about it, wouldn’t it be better to have a block of instruction that was well attended than a patchwork of conferences which people can always find an excuse (and usually good ones) to miss?

    I even think surgery could use a shift system, especially fro elective surgeries. Why, for example, should the ORs be sitting empty for half of the day?

    But you know, the problem is that everybody does things the same way. If some residency programs went to a shift system, they might attract those people who would rather work shifts than take call. Those who don’t like working shifts could only rank programs that worked the traditional schedule.

    The problem is that because there is no real protection for residents (even the 80 hour work week), the system has evolved in the only way it possibly could, that is, into one which takes as much advantage of its cheap, captive labor as it possibly can.

  18. I am frankly fed up with non-physicians telling me I should be “grateful”, “privileged” and “honored” to be a doctor. How dare you make such preposterous remarks? Panda Bear, myself as well as many others have endured 8 years of rigorous training BEFORE residency and
    more than fifty percent of it now arguably at best, unimportant and at worst, obselete.
    So please stop acting like our degrees were handed to us on a golden plate one day.

    Obviously, no one forced us into it and we could have opted out at anytime, even now.

    With respect to being subjected to abuse, God knows most of my resident colleagues blend one into the other as a spineless, supine, passive group who for some reason, have abandoned critical thinking and swallowed their pride for some abstract sense of satisfaction that comes with pleasing the attending. Training, like mnay things in life, is simply what YOU make of it. Never let anyone push you around because if you stand up for something, you will fall for anything.

  19. I have a good friend who is an intern who strikes fear into the hearts of his off-service attendings because, while he is never rude or anything but perfectly correct, he refuses to put up with any of the “unwritten” crap.

  20. “I love your blog…just looking for something positive about your colleagues, training, improved skill set, positive patient outcomes….something to tell me you enjoy what you do”

    if you love his blog, then i can only assume you’ve read it. then the problem would concern your memory–pb devotes at least one full entry to what he enjoys about medicine, and he commonly mentions things he likes about it.

  21. I think I have the intestinal fortitude to handle all of the problems that you’ve had to deal with, except one: sleep deprivation. I HATE being dead tired. I’ve known for a while now that residency training is an inefficient, anachronistic, abusive system, but having to think when you’re dead tired is sheer torture.

    I am really gonna have to toughen up over then next year and a half!

  22. I second what Bob says. Your attending reminded me of my old boss at the industrial supply company from hell. Actually a few of them. Oh well. At least when I confront this during rotations and residency I’ll have seen it before.

  23. Sounds like a terrible experience Panda, that is too bad. I do take some issue though with the idea that all internists and especially the academics are worthless, which appears to be the overriding sentiment in this discussion.

    I am an internist and will gladly admit that some of my colleagues are worthless buffoons. So are some surgeons, some ED docs, some OBGyns, and so on.

    What exactly do academic internists do you ask? Some of them do an incredible job of taking an unintelligible mass of seemingly unrelated signs, symptoms, and labs to uncover the answer to a patient’s problem. Some of them, are buttheads.

    The medical world needs fleas (internists), just like it needs the people that think that “nothing heals like cold steel” as well as the people that admit every troponin of 0.02.

  24. I have the deepest respect for internists as anyone who reads my blog regularly knows even though I would never want to be one. Internal medicine, with general surgery, is the backbone of the medical profession and without whom we are all just a bunch of prima donnas with out thumbs up our asses.

    I agree with your comment and, while I sometimes joke about the obsession of the internist for the minutiae, let’s admit that it’s just a joke and we’re all secretly glad that those tenacious fellows are willing to track down every medical lead.

    Their are two things I hate, stereotyping of medical specialties and those lazy PM&R bastards.

  25. you know that every hospital, residency, and specialty program is different and have different ways of covering “shifts”.

    i can say from the surgical end, shifts do not solve the problem. because most of the surgical volume in done during the day (M-F), the night shift person gets hosed and that persons case load goes down and they become babysitters and ER consult jockeys.

    so shifts don’t solve everything. the other thing is very good programs have “protected lecture time.” we have a morning (with grand rounds, anatomy, etc.) and an afternoon (4-6pm, a time requested by the residents by the way) conference. these are protected times; faculty is expected to complete cases and clinics without resident service.

    many programs that i have been involved with have been steadily increasing the number of midlevel providers to decrease the work load for residents.

    question for you dr. bear, what amount of training is enough to make a competent physician? from my personal experience, experience is everything and most of what we do is not written in any book. So when is it enough and we don’t put patients at risk? As you know, your clinical acumen can not be tested on a multiple choice test and your ability to deal with patients and their social dynamic can not be taught in a web based course.

  26. Depends on the specialty. And depends on the program. I think we probably all need more time than we currently receive, on the other hand we can’t live like paupers for a huge chunk of our productive years.

    And a lot of residency time is utterly wasted. Filling out forms trains you for nothing but filling out forms and we do an awful lot of that and it is mostly pointless. And not all training time is good training.

    Let me give you a little example. I recently had a radiology week. I could have shadowed and annoyed a radiologist for a week but instead I took a radiology book home and finally got a handle on all of those carpal bones and other things I have been putting off.

    On a similar note, I have done quite a few surgery rotations and as on most of them (except my last trauma rotation)my entire job whether I wanted it to be or not was wrangling paperwork which was entirely wasted time. Everything I learned of use could have been compressed into a couple of hours and the scut I had to go through to learn it, scut that kept me from reading on my own, wasn’t worth what I learned.

  27. And I believe I proposed that the whole teaching hospital go to a shift system and run, in your case, the elective cases at all hours. I don’t know about surgery but at our hospital, internal medicine is a 24-hour a day operation and for reasons beyond the ken of man, we have more admissions and work at night.

  28. the problem with the whole system switching to a shift system is that not all services function that way. hospitals OR can not run elective cases 24/7 (as much as i want them to extend the hours). inpatient services are 24/7 services, that is true, but what about outpatient services? most outpatient services are 7am-6pm type services. what about clinic based services? what about completely elective services? although, i do believe that many services can run on a shift system, not all run well on that type system.

    the other thing is not all hospitals have residencies for every service. for example, in all of phoenix,az, there are only ~2 orthopaedic spots per year and it is ~5th largest city in the united states. they function very well without residents. there are many hospitals that have only one or 2 residents. larger university systems, especially those thick with tradition, are a little hard to change, the mentality that is. those are also some of the places with a significant amount of DSM-IV diagnosis within the attending hierarchy.

    each program is dealing with the situation in it’s own ways. some of the problem has to do with the hospitals and some with the actual departments. it all boils down to money. who is going to pay for ancillary staff etc. because most of the university practices have gone to multispecialty groups, they are not always directly tied to the hospital. the hospitals fee (facility fee) and the physicians fee (professional fee) are separate; there are 2 separate budgets. sometimes a low yield department can not afford to hire ancillary staff and therefore need hospitals assistance. profitable specialties, i am fortunate to be in one of them, have no problem increasing ancillary support.

    so there are problems at multiple levels, and i don’t think there is an easy fix. personally, our faculty are always looking for ways to increase learning experience while improving overall care of patients. and you’ll love this, in the end it is all about patient care. 🙂

  29. I appreciate your knowledgable input. I never said there was an easy fix and I am certainly not proposing that one solution will fit everybody. There are, for example, medicine programs with extremely limited call but an extensive night float system for the residents. To my mind, having some variety in pay, training hours, and shift versus call would be a good thing and prospective residents could factor these into their ranking decisions.

  30. having variations in pay based on call would be a good option. in truth, i have no really good understanding of the internal medicine system, being raised in the surgery system.

    you have a lot of good input and thought into the system. have you ever thought about being a part of the LCGME or resident committees where you can help in influencing change? i can tell you from my experience of being the admin chief of my residency, being on these committees opens your eyes to another world of hierarchy, DSM-IV pathology, and politics.

  31. With respect to “Someone Interested’s” comment – couldn’t it be a rotating shift system? I know a residency program that operates in three, 8-hour shifts. You take the morning shift, then you take the next day’s afternoon shift, and so on. You’d have to lengthen the shift for surgery and didactics, but the ER night consult would be spread around. Being up night’s would be much less of an effort because you’d always be in a pattern and only stretching your day cycle a bit.

  32. Having read this, and read the comments I find I’m frankly astounded that medical services of all people have retained a frankly moronic and highly unsafe set of working practices.

    Pilots have legally-mandated working hours and shifts. Lorry drivers have this system, and so do most professions where deadly machinery is being operated.

    So why, when you’re working in medicine, when lack of concentration and fatigue literally WILL cost lives, why is an archaic working system which dozens of studies have demonstrated to be lethally dangerous to patients; why is the system still in place?

    Secondly, with regards difficult management my advice is to put up with them if you have to but as soon as decently possible get out from under their control by fair means or foul. Crap managers do not reform, they don’t get less aggressive and they never grow a brain. All they do is get devious and better at manipulating you as they get to know you.

    If you want to play politics with a crap manager, for goodness’ sakes wait until an opportune moment and land them in the largest amount of hot water possible at the worst possible moment you can; no half measures, no messing and absolutely no warnings.

    If you don’t fancy that, just walk away and leave them to it. Word gets round, eventually, and morons have no friends. They’ll reap what they sowed in the end, in the mean time just get out of their way.

  33. dr. dan h, it sounds like you have a good story to tell…”and land them in the largest amount of hot water possible at the worst possible moment you can; no half measures, no messing and absolutely no warnings.”

    mind sharing?

  34. “During my training, I was excited to get each meager paycheck since it was the most I had ever earned up to that point.”

    Um, I’ve worked less than 80 hours a week as an entry-level landscaper and made more than I will as a resident. My wife makes about 3x per hour as much as a resident (if you assume 80 hours a week with paid overtime) as a nurse, and she did so when she was 20 with an associates degree. I’ll be 26, with an M.D., making less. The excitement is not exactly boundless, suffice it to say.

  35. Not a doc. Never even played one on TV. But I love medblogs, and, as a writer, nothing scratches my literry itch more than great writing. You have it in spades.

    Great FOAD letter. The attending probably would have stroked just reading it.

  36. Nicely written.

    Now too bad we can’t get around having to work with nasty people like that. At least it’s only a month. Can you imagine the poor fools that have to work with them for their whole residency?!

  37. Dear Panda – just one thing: it’s not fair to call PM&R docs “lazy bastards.” I did 2 years of EM and 3 years of PM&R residency training. All the things you hate about residency (sleep deprivation, rudeness, outrageous pimping, harassment, etc.) pretty much go away in PM&R. While you consider how to fix the experience (with shift work and such) consider that the PM&R residents are already enjoying what you are striving for. Does that make them lazy… or wise? PM&R has a lot to offer – freedom to do anything from sports medicine to interventional pain management, to inpatient TBIs/SCI. We do cool research in bionics and prosthetics, find creative ways to get people functional again, and enjoy a great lifestyle with a good salary. You might want to switch residencies again… 🙂 I guarantee you’d feel physically better if you did.

  38. Dude, it’s just a little running gag here on Panda Bear, MD. I am just joking.

    I do not think people in PM&R are lazy.

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