THE CASE OF DR. X

1. THE CASE OF DR.X

2. BACKGROUND • Transfer from another program to your PGY2 year • USMLE Step 1 & 2 scores 200 range • “Highly recommended” with superior clinical competence, knowledge base, and maturity • Chair Letter: Will excel in your program

3. First Rotation - Elective • Satisfactory, but presentation skills need improvement • Trouble organizing the case and coming up with differential diagnosis

4. Second Rotation – Hematology/Oncology Ward Nursing concerns surface over his responses and reactions to calls and are reported to Chief Residents: • High K+ - didn’t respond readily • Febrile neutropenic patient, nurse identifies possible tunnel catheter skin infection – resident unconcerned, fellow had to initiate management

5. Second Rotation – Hematology/Oncology Ward(cont’d) • Irregular heart rhythm detected in patient being transported to radiology after multiple failed LP attempts – “I am not concerned, he just got poked several times in his back”. Patient experiences oxygen desaturation after procedure!

6. Second Rotation – Hematology/Oncology Ward(cont’d) • GI fellow concerns about team performance regarding a patient with GI bleed • End-of-month evaluations from teaching attending and intern do not allude to significant concerns • Chief Residents counsel Dr. X: casual responses are inappropriate with regard to acuity of illness seen in this hospital

7. Third Rotation – Geriatrics Outpatient • No concerns raised

8. Fourth Rotation – Night Float • No problems reported by intern • Some residents on day teams expressed concern to Chief Residents regarding: • Aspects of judgment • Ability to prioritize patient problems • Breadth of differential diagnosis

9. Fifth Rotation – Inpatient Medicine • Teaching attending evaluation: well-organized, team run well, added to quality of discussions about cases, sought feedback

10. Fifth Rotation – Inpatient Medicine(cont’d) • Intern evaluations: • appeared to be self-motivated to learn more about medicine and demonstrated an interest in teaching. • Not especially strong at applying knowledge to clinical situations.

11. Fifth Rotation – Inpatient Medicine(cont’d) • More interested in looking for “zebras” than delivering good basic care. • Had somewhat limited first-hand knowledge of our patients. • Don’t think he passes the basic test “would you want this person to provide care for one of your loved ones?”

12. Sixth Rotation - MICU Attending comments during and after the month: • Dr. X had difficulty quickly assessing and implementing care on critically ill patients • At times sloppy with data gathering and reporting • Oral presentations poorly organized and often mumbles and does not engender confidence in the listener

13. Sixth Rotation – MICU(cont’d) • Written communication often sloppy and illegible • Poor organizational skills, confusing presentations, make it difficult to follow his thought processes • Needs substantial work at presentation skills, formulating and expressing assessments and plans, learning a problem- and systems-oriented approach to patient care

14. Sixth Rotation – MICU(cont’d) • Earnest, hard-working, cares about patients Bottom line: We have serious concerns about his ability to function as a senior resident, and believe he should repeat the rotation

15. What should be done about Dr. X?