How to deal with devastating criticism

“Why don’t you just get a shotgun and blow his brains out next time? Better yet, next time stay the hell away from my patient!”

I was frozen, and the ICU attending wasn’t even talking to me. My co-intern had barely started her presentation when she met damnation. Mind you — there was a senior resident, a pulmonary fellow, and a team of nurses caring for the patient also. Yet the intern bore the brunt of the criticism. Health care is often like this and can feel like a dog-eat-dog world with a rigid hierarchy and archaic rituals.

I still find myself thinking about my internship in 2008, a monumental year in my path to becoming a physician. I worked long hours, had profound teachers, forged lifelong friendships and was privileged to take care of the underserved in New York. Despite this, I also had some interactions that left me on the verge of tears, shaking with anger and doubting whether I could truly be a physician.

One of these still haunts me. I was the first to respond to a syncopal episode in the dialysis unit. I examined the patient (who was fine), reviewed the chart, conferred with the nurse and ordered some IV fluids. When I saw the nephrology attending I expected praise for my efficiency. Instead, I received admonition: “You are the worst intern I have ever encountered!” I could feel my entire face quivering and an avalanche of tears forming. What had I done that was so terrible? He continued his attack while nurses looked on. “That is my patient, and you didn’t even call me to ask my opinion. No one has acted this way in my 30-year career.” I mustered up enough courage to say, “I’m sorry.” Truthfully, I was only sorry that I couldn’t read his mind. I avoided that attending for the next six months until my internship ended. His words echoed in my mind — “worst intern ever.”

Since becoming an attending in 2012, I’m usually no longer berated in front of colleagues. Despite this, I do deal with scared and angry patients and their families, as well as with overworked and stressed healthcare professionals. Nowadays, most of the criticism I get is from department heads, hospital administrators or the patient relations department.

This is my advice for dealing with devastating criticism:

1. Change something if needed

During my first week of internship, I was a part of two preventable medical errors, and the feedback I received helped shape my learning for the rest of my career. My team admitted a patient with uncontrolled diabetes in diabetic ketoacidosis, and I wrote an incorrect insulin dosing schedule. Since we had paper orders, they were faithfully executed overnight by nurses without any EMR warning screen. Unsurprisingly, our patient was not better by the morning. My teaching Attending came to me on rounds and said: “I know you’re new and I’ve been in your position … but this cannot happen again.” That was it: No raised voice, just genuine concern for our patient.

A week later, another patient, and another blunder. Somehow, I had ordered a long-acting blood pressure medication, and neglected to discontinue the short-acting drug. Again, my paper-based doctors’ orders were efficiently executed by the nurse. Thankfully after some careful monitoring — ultimately no harm resulted. I’ve been obsessed with medical errors since then, and in actively implementing strategies to reduce the chances that I become a contributing factor.

2. Learn the rules of the game

Dr. A likes labs presented a certain way, Dr. Z likes medical students to be at the front and center of case presentations and Dr. Q wants you all to shut the hell up, be invisible and listen to the “real doctors.” All of it is irrelevant in the end, and yet all of it is vitally important for your training. Millions have come before you through this gauntlet. Repeat after me: Learn the rules of the game, and you will survive.

3. Develop resilience

Dr. C was a mercurial surgeon I had to work with during my third year of medical school. On a particularly terrifying occasion, he put down all his instruments, stopped the case and stared down an anesthesiologist and growled, “Don’t do a goddamn thing without me telling you to.” Her crime? Being worried enough about tenuous blood pressures to recommend a blood transfusion. Outside of the OR, she lamented, “He’s an ass but a great surgeon — you’ll get used to him if you remember it’s not personal.” Some of your tormentors may have personality disorders, but most others are influenced by factors that you have no control over. Your survival depends on your formulating strategies to become more resilient. With physician burnout now at the forefront of national discussions, suggesting an approach of building resilience can seem like “blaming the victim.” However, external factors aren’t in our control and culture takes decades to change. Our own response to attacks can either determine a speedy self-recovery or a prolonged suffering.

4. Resolve to be better in your own interactions

I’ve made it a goal to not turn into someone I hate. Despite this, I’ve had my momentarily despicable episodes. In one of my first jobs — I remember an episode becoming extremely irate with a nurse after she openly questioned my management in front of a patient’s family. I cut her off mid-sentence, presented her with the science, reiterated my sound treatment plan and then stormed off dramatically. However, I returned to the unit 10 minutes later to apologize for my actions. I remembered how horrible the nephrologist had made me feel and realized that she was speaking out in the interest of patient’s safety. I obviously should have acted differently. It takes conscious effort to follow the golden rule and not become that which you despise.

Varun Verma is an internal medicine physician who blogs at his self-titled site, Varun Verma, M.D., and can be reached on Twitter @VarunVermaMD.

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