As a third-year medical student, fresh and green on my clerkship rotations, I was determined to stand out on my general surgery team. I knew this was not going to be easy; I was often the last item on many surgeons’ minds as they rush through morning pre-rounds at the hospital, flying around corners, their Nike sneakers squeaking on the polished white floors.
In the OR, I observed from the corner, watching a crowd of surgeons, draped in flimsy, powder blue gowns, huddled shoulder-to-shoulder around a patient, their metallic instruments clinking as they rattled off surgical terminology. I felt like an insect that had scurried under a doorframe.
I eventually asked my senior resident if I could present one of our patients on morning rounds. “Yeah, sure,” she said. “Go see Mr. X with the arm abscess.” This was it. I downed my morning coffee, rubbed the fatigue out of my puffier-than-usual eyes, and headed down the barren hall at six in the morning to annoy this unknowing patient with a barrage of questions and exam techniques. When did you first notice the swelling? Is there pain? Can you describe it? I scribbled my notes on the patient list in my coffee-stained white coat, and I was ready to go.
Just as we pulled up to the unit, my attending asked, “OK, who’s next on the list?” I cleared the Arabica phlegm from my throat, my heartbeat drumming in my ears, pulled out my neatly folded patient manuscript and rocketed through my presentation, while my attending, thin and towering like a real-life dementor, shifted his emotionless, shark-like eyes to me, crossed his arms, and listened in silence. “So far I haven’t been interrupted,” I thought. “I must be doing it right!” The slight tremor in my fingertips had started to calm. Describing my physical exam, I said, “There is a three- by four-centimeter erythematous abscess formation on the proximal forearm, with overlying skin intact and no obvious leakage or purulence.”
“Is abscess an assessment or a physical exam finding?” my attending asked.
My stomach somersaulted. “Oh … I suppose it’s an assessment. So, I’d say it’s a fluid-containing mass,” I said.
“What on physical exam makes you think there’s fluid in it?” he asked.
The fog began to roll over my brain as I searched for the answer, my vision practically greying. “Uh …” I sputtered to buy me time. My attending’s eyes drifted away. My intern twirled his fingers over his own forearm and mouthed something. What was he saying? Something that starts with an “F” for sure. Oh! Fluctuance! “Fluctuance,” I said.
“OK, so what are we doing for this man?” he asked exasperatedly. I proposed that we do an incision and drainage and start some antibiotics. “What antibiotic do you want to start?” I had just researched this, but the fatigue and panic that was building inside my skull inhibited me from finding the answer. “I’m not sure …” I said.
My attending pivoted on his heels, arms strapped across his chest, and relayed the plan to my senior resident. And that was it. My posture sank in defeat, and I was left to question my utility as the group zoomed away in front of me, their long white coats floating in the air behind them. I had just been “pimped”— questioned to show the holes in my knowledge.
Throughout my clerkship rotations and into my fourth year, I was aware that something in this exchange caused me to feel limited and small, even if I couldn’t label what “it” was. Eventually, I came across the term negativity bias — the concept that we as humans naturally place more emphasis on negative information in our environment than on positive information. When my attending physician decided to focus on the one mishap I had during my presentation, he devalued the positive work I had done and allowed me to believe that I was not living up to expectations.
Negativity bias persists in medical training because it’s efficient and incredibly effective for certain kinds of learning. Information learned in a negative setting is quicker to be absorbed and more resistant to extinction, and in a time-limited environment, it’s easy to understand how teaching techniques like “pimping” have persisted.
However, research has also shown that negativity bias stunts creativity, causing med students and internists alike to have a more limited differential and take longer to arrive to the correct diagnosis when negatively engaged by the questioner. Even when I got answers correct, I often felt like I was throwing up mental roadblocks and editing my thoughts for fear of making a mistake, knowing I could face scrutiny from my superiors if I answered wrong.
This is especially important given the disproportionally high rate of burnout and depression in medicine. As much as I wish I could say I was unaffected by my surgical attending’s callous demeanor, it’s just not true. Because of his fixation on my mistake and other similar experiences during my surgical rotation, I periodically felt emotionally exhausted and wondered if I was good enough to be a physician, despite all the other pieces of evidence that indicated I was a more than capable student.
While negativity bias may be a “default” setting for most adult human beings, it is certainly malleable and can be ameliorated through simple techniques: giving praise to a medical student, thanking a colleague for their consult, or even keeping a “what went well” journal may be effective measures to combat the toxicity of negativity bias.
My best experiences in med school were those in which I felt appreciated by my team, praised for what I did know, and encouraged by my attendings to follow my intellectual curiosity. Unlike my surgical rotation, those experiences made me proud to be a medical student and optimistic about my future as a physician.
Jay Thetford is a medical student.
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