It's all about trust

I completed the nomination forms for graduation awards for clinical faculty and students. The docs that I nominated were folks who I thought deserved it, but my votes for students were not exactly predictable. I would guess that none of the people I voted for have any chance at winning. At the onset, I tried to come up with a set of qualities and traits to rank people, but in the end, it really just boiled down to trust. Do I trust this person?

On my sub-I, I consulted an attending whom I'd worked with before. I told him about the patient, and he took my presentation at face value. He didn't have to. I'm a student. As an attending, it's his right to talk to my attending, or my senior resident, or even my intern. He doesn't have to take my word for it. But he trusted that I was giving him the whole picture, and that I would follow up on what he had said. And that's something.

Attendings have the liberty of avoiding scut work in house, but they have to trust that the residents will get it done, and rely on the work of the residents to base all of their clinical decisions. That's a lot of trust. Some attendings don't trust the residents or students at all. I know several attendings who repeat the entire comprehensive physical exam on every patient they see. Some check all the labs themselves, not trusting that the numbers we've written in our notes.

Everything after trust can be worked on. You can teach a person knowledge and judgment and clinical skill. You can't teach someone to be trustworthy. And that's why I didn't vote for some of my classmates. When the rubber hits the road, I just don't trust that they'd get the job done.

As an example, on my sub-I, there were a couple personal emergencies, and as a result, I was the only person on my service. No senior. No interns. I had to work with an intern pulled from another service to emergency cover. As we rounded, it became plainly obvious that the lists for the patients were not up to date, and we were paralyzed because we were spending all our time figuring out what medications our patients were on. The 3rd year students are supposed to keep those lists up to date, but they hadn't been keeping up.

After rounds, I had a talk with my students. I was nice. I said that it's important for them to keep their patients' lists up to date to avoid what happened. And from that day, I watched the list. There's truly no better, objective measure of a medical student than asking him to do the most trivial task on a daily basis.

When someone follows through on that, you know that you've got a winner. Because that student has shown the desire to earn your trust. And if someone can be trusted with minor things, than perhaps he can be trusted with greater things. And when a student doesn't follow through on something as simple as updating a list, that tells you something too. If someone can't be trusted to do something as trivial as update a list, how can he be trusted with something major, like the lives of his patients?

One of my students, my gunner, she was great. I could ask her to do something, and I knew that she would do it. She called people. She got old records. She tracked down a patient's baseline creatinine. She got the name of a patient's psychiatrist, of all things. She's a 3rd year, and she's got a ways to go with history taking and that stuff, but you can learn that crap. You can't learn being trustworthy. If I was a resident, I'd take her as my intern any day of the week and twice on Sundays. If we were picking teams, she'd be my first pick.

My slacker, it got to the point where I just couldn't trust her to get the basic stuff done: writing notes, updating the list, checking the labs, stuff like that. I had to ask her every day if she even saw her patients. I blame myself to some extent. I should've corrected this behavior from the get-go. But the heart of the matter is simply that I couldn't trust her.

So I'm glad that some of my classmates are going into fields without direct patient care or are far removed from internal medicine. I'd rather work with people I trust. And that's how I voted for the graduation awards. Despite all the flourish and prose written to encompass the awards, to me it boiled down to this: who would I trust to care for me? And when presented with that question, the answers were quite simple.