UBC Objectives: Family Medicine, UBC Objectives: Behavioural Medicine & Resident Wellness, UBC Objectives: Women's Health, & UBC Objectives: Care of Men
By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Disclaimer: Okay, so this post makes me feel like I'm tooting my own horn, really loudly. It feels unpalatable to be demonstrating the achievement of competencies that are pretty well synonymous with being a good person. It feels disingenuous, as though I've acted in a caring way toward someone and then turned around immediately to the person behind me and said, "See, I am a good person." But as part of this reflective blog that is mapped to my learning objectives, with the intent being that I will have exemplified proficiency of each one by the time I finish residency, a little horn-tooting is just my attempt to demonstrating this proficiency.
Today was one of four days during my month-long rotation at Three Bridges where I was supposed to video-record my entire encounter with a patient, from introductions until the end of the visit. The point of this was so that I could review it with my attending physician that day and receive feedback on my clinical skills. I knew I needed to find a patient who would give consent to being the recorded patient, and that some patients would probably decline, so I knew it wouldn't be smart to wait until the end of the day to ask patients to help me out with this. Being the super nonprocrastinator that I am, I asked my very first patient, and to my surprise, they agreed for me to record our encounter! This patient was a 49 year old trans patient who identifies as non-binary and who prefers to go by "they/them" pronouns. They turned out to be lovely and probably the easiest person in Vancouver to get a taped interview with.
The patient was coming in for follow-up regarding testosterone therapy. They started testosterone 3 months ago and had been gradually going up on their dose. Their goal was to have the appearance of an adolescent male, and they were well on their way. Prior to meeting this patient, I really had only explored management of testosterone therapy with patients who identified as male and who wanted to appear as masculine as they felt, without significant risks to their health that can accompany overzealous hormone therapy. This patient's hormone goals were not quite so polar. I had the opportunity to explore this with them, and much more. At times I almost (but not quite) forgot that the interview was being taped - I was enthralled in how they spent their time volunteering as part of a gay nuns advocacy group (aka the Sisters of Perpetual Indulgence) and how they had plans in the next year to cycle across Canada (one of the highest items on my bucket list). Although we did get somewhat derailed talking about The Great Trail, we also did spend most of our time together talking about issues regarding their health. The interview flowed, and next thing I knew it was 30 minutes later and I was shutting off the video recorder.
My attending physician sat down with me over our lunch break (we're even productive on our lunch breaks!) and reviewed the video with me. I felt vulnerable in anticipation of receiving feedback regarding how competent I was on the wannabe family doctor scale, which today was graded in 3 categories as either 1. Needs improvement, 2. Satisfactory, or 3. Effective. The observed areas on which I was assessed included
To retoot the horn that my attending surprisingly tooted for me this afternoon, I achieved an E for effective in the first 5 categories and I received an S for satisfactory in the area of Efficiency. I was given specific feedback as to why I earned an E for effective in 5 of the categories (such as demonstrating active listening, being patient-centered in my interview style, and by way of verbal and nonverbal skills expressing empathy, unconditional positive regard, and genuineness toward the patient). My preceptor felt that I only attained an S for satisfactory on the 6th category since I spent more time than indicated talking about the fun and interesting but not medically relevant aspects of this patient's life. I felt this was a fair critique and that the interview would've certainly been more efficient by having a little less banter overall. As well, for critical but not corrective feedback I was told that I tend to have a very exuberant energy, and that while this was seemingly well-received by this patient and likely many others, it may be just too exuberant in some settings, and that it would be good for me to be aware of this if I wasn't already. I agree with this point of feedback and think it is important to be able to adjust body language and tone of voice to fit the context. I do think I am competent at recognising when it is time to pop the champagne bottle or instead to vent off most of the gas in my personality bubbles, letting things flatten out in those patient encounters that call for a bit more poise and solemnity. Perhaps my next video-recorded session will speak to my ability or inability to reflect this.
As a resident, it seems as though we are mostly learning what to do by learning from our mistakes, which can get a bit demoralising. And even when we receive positive feedback, having the perfectionist personalities that we do, we tend to focus on what we've done wrong rather than spend time acknowledging the accomplishments we've achieved. At the end of this interview, the patient asked me when I was going to graduate. I told her I have another year and a half of residency yet (thank goodness, I am so far from ready to practice independently). She then said that was disappointing as she was wanting to see if I could be her family doctor! I would say that meant I achieved competency in establishing a strong doctor-patient relationship and therapeutic alliance, which sort of means the world to me right now. So for now - and probably not for long - my horn is a-toot :)