Promising Young Surgeon | Season 2 Episode 7

Hidden Curriculum in Medicine with Dr. Joanne Loethen

In this week’s episode of Promising Young Surgeon, we delve into the hidden curriculum of medical training with Dr. Joanne Loethen. The hidden curriculum encompasses the informal lessons imparted through respect, language, demeanor, and attitude towards colleagues, team members, and patients. Dr. Loethen, an assistant professor of internal medicine and pediatrics at the University of Missouri Kansas City, shares her insights on how these unspoken rules shape the professional environment in hospitals and medical schools.

Dr. Loethen also talks about her non-traditional path to medicine, the importance of maintaining fitness and nutrition during medical training, and practical advice for residents on optimizing their well-being. She emphasizes the significance of professional skills, empathy, and teamwork in medical practice, and how these elements are often part of the hidden curriculum that residents learn through observation and experience.

Published on
June 18, 2024

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Unveiling the Hidden Curriculum in Medical Training with Dr. Joanne Loethen

This week we are discussing the hidden curriculum of medical training

Dr. Frances Mei Hardin: Welcome to this week’s episode of Promising Young Surgeon. This week we are discussing the hidden curriculum of medical training. The hidden curriculum of medical training includes the informal lessons that we teach through the respect, language, demeanor and attitude displayed towards colleagues, team members and patients. For some context, medical school focuses on fundamental scientific and pathophysiologic principles, systems based learning, medical ethics and professionalism, population health and academic research, residency and fellowship focus on patient care, application of clinical knowledge, team based care, effective communication and interpersonal skills, as well as professionalism. And then the hidden curriculum refers to things like power dynamics, including hierarchies in the hospital, gender roles and expectations, cultural and societal values, social skills and work ethic. The hidden curriculum also includes what professionalism in practice really looks like.

Canadian study examines residents reluctance to challenge negative hierarchy in the operating room

So today we’re going to start off with a really fun journal article review this is about hierarchy in the OR and I love this study is from Canada. It came out in 2015. It’s titled residents reluctance to challenge negative hierarchy in the operating room, a qualitative study by Bold et al. So we’re going to go through this in detail together today before we jump into discussion with Doctor Loethen, and of course we’ll link this study here at the bottom, but let’s go through the abstract first. Purpose our aim was to clarify how hierarchy influences residences reluctance to challenge authority with respect to clearly erroneous medical decision making. The methods for this study were as after research ethics approval, we recruited 44 anesthesia residents for a high fidelity simulation scenario at two Ontario universities. During the scenario, an actor whom the residents were told was an actual new staff anesthesiologist at their university asked the trainees to give blood to a Jehovah’s Witness in contradiction to the patient’s explicitly stated wishes. Following the case, the trainees were debriefed and interviewed for 30 to 40 minutes. The interviews were audio recorded and transcribed verbatim and the text was coded using a qualitative approach informed by grounded theory. The results of the qualitative analysis of the participants interviews yielded rich descriptive accounts of hierarchical influences often characterized by fear and intimidation. Residents spoke about their coping strategies, which included adaptability, avoiding conflict, using inquiry as a method for patient advocacy, and relying on a diffusion of responsibility within the larger operating room team. Conclusions study results showed hierarchy played a dominant role in the functioning of the operating room. Participants spoke of both positive and negative effects of such a hierarchical learning environment. The majority of participants described a negative perception of hierarchy as the norm, and they employed many coping strategies. This study provides insight into how a negative hierarchical culture can adversely impact patient safety, resident learning, and team functioning. We propose a theoretical model to describe challenging authority in this context. So, like I said, I love this study, and I think it’s so savage, too, because not only is it a pretty bad gig to be a resident, but these guys also got experimented on. So I’d like to comb through, and I’ve selected some quotes, you know, throughout the text and then from the resident interviews themselves that we’ll just highlight here. So I really loved, like, in their introduction, they kind of set the scene very well. I’ll read some of these lines here. The perioperative environment is characterized by relatively large and complex teams, with members at different levels of training and with varied roles in high acuity, time critical situations. Perioperative teamwork exists within a context of both explicit and implicit hierarchies. There are multiple power gradients within and between different professions and medical specialties. For instance, while there’s a clear line of command between an attending anesthesiologist and their resident, there may be a less formal status asymmetry between anesthesia and nursing, and more fluid power relations between surgery and anesthesia. For instance, while there is a clear line of command between attending anesthesiologists and their residents, there may be a less formal status asymmetry between anesthesia and nursing, and more fluid power relations between surgery and anesthesia, depending on the individual physicians and clinical context. So, again, this article didn’t really tell me anything new, but there’s so much that people don’t believe until they see it in an academic journal article. And so I love how this provides some structure and some real qualitative studies and quotes under the results section, they do include snippets of the resident interviews. So, under hierarchy and some of those interview questions, the interviewer said, how do you know that there is that hierarchy? Like, I mean, it’s not. Is it taught in school? Is it taught like, okay, you’re resident three. It’s embedded into you from day one of medical training. Resident 26. Because the hierarchy is well established with the surgical staff and, like, revered, I think they pride themselves on sort of abusing the junior residents. Factors affecting positioning within the hierarchy. Resident seven stated. Plus, I think oftentimes there’s gender issues. Absolutely. You know, whether it’s a female anesthesiologist, male surgeon, or vice versa, it’s. Sometimes I find it difficult to bridge the hierarchy when there’s gender differences.

Residents cited numerous situations where power differentials negatively affected patient care

Importantly, I really want to highlight this section of the results effects of a hierarchical team climate on patient care. Residents cited numerous situations of the negative effects of power differentials on actual patient care, that is, where negative outcomes could have been avoided if trainees were permitted to contribute more of their knowledge and skills within the perioperative team. Examples included instances where surgeons continued to operate despite the insistence of members of the anesthesia team that the patient was too unstable. This resulted in excessive blood loss and its sequela and the administration of inappropriate doses of anesthetic drugs, which led to negative patient outcomes. And so, you know, in the discussion and conclusions of this study, basically residents described a steep hierarchy as an inevitable feature of the perioperative environment that played a dominant role in operating room functioning. This hierarchy was described as often having negative effects on the well being of trainees as well as on learning and patient safety. I love this point that they make at the end where they do describe in contrast, Rabaul et al have published on a quote unquote flat hierarchy between nurses and doctors in Denmark and that facilitates communication. They cited the egalitarian society of Denmark as a potential cause and point out structural issues that hint at the effect of the hidden curriculum. So their salaries are fairly similar between nurses and physicians. And so it’s just interesting to see how some of these themes are cultural. And certainly in this study, you know, there’s a lot about the culture of north american ors that is coming to the forefront.

Doctor Joanne Loethen practices primary care in Kansas City, Missouri. She is boarded in internal medicine, pediatrics and obesity medicine. She is an assistant professor of internal medicine and pediatrics at the University of Missouri Kansas City. Doctor Loethen was a division one softball player at the University of Missouri as she obtained a bachelor’s degree in nutrition and fitness, then a master’s in exercise physiology. This was followed by a career as a health coach and fitness mentor along with roles in cardiac rehab and clinical exercise testing. She ultimately decided to pursue a career in medicine at the age of 29 and she then attended medical school at Michigan State University, followed by a four year combined residency in internal medicine and pediatrics at the University of Missouri Kansas City. She served as chief resident of the internal medicine program of UMKC and House staff president of the UMKC’s residency programs. Aside from her clinical work, she has engaged with quality and process improvement with her healthcare institutional, specifically looking at how to expand and enhance primary care in a way that preserves quality, improves patient outcomes, and provides a sustainable work environment for every member of the healthcare team. She is actively engaged in physician advocacy and organized medicine, serving roles within her local, state and national medical associations.

Doctor Loethen is a leading physician voice on rethinking residency

Thank you so much for joining me today, Doctor Loethen, thanks so much for having me.

Dr. Joanne Loethen: This is such an honor.

Dr. Frances Mei Hardin: It’s so great to see you again. And you know, doctor Loethen and I do go way back because we were members of the Missouri State Medical association resident and fellow section back in the day.

Dr. Joanne Loethen: We were.

Dr. Frances Mei Hardin: And I really do want to say as a quick plug, that I have loved your bi weekly column on the hidden curriculum of medical training on rethinking residency. And it is your unique background, experience, skill set and passion for medical education as well as physician advocacy that uniquely positions you as a leading physician voice on this topic.

Dr. Joanne Loethen: Thank you so much. It’s been, such a joy to explore that topic because I think it’s something that we need to talk more about.

Your practice allows residents to have their own panel of patients

Dr. Frances Mei Hardin: So just jumping into things here, what is your relationship to residents in your program and as part of your practice?

Dr. Joanne Loethen: As my current practice, I work with residents in clinic who are rotating through their primary care rotations or, we have a continuity clinic. So typically every five weeks, residents come through the clinic and they own their own panel of patients. And I, am a faculty who helps oversee that practice.

Dr. Frances Mei Hardin: Wow, that’s awesome. Is that for internal medicine residents, that they get to have their own patient population in that setting?

Dr. Joanne Loethen: Yeah, internal medicine, and then also our med peds or internal medicine and pediatrics residents get that as well. it’s part of the, you know, helping them relate to primary care and what it might be like in the real world. So we help them own patient experiences and patient care, by having their own panel of patients overseen, of course, by faculty.

Dr. Frances Mei Hardin: That’s awesome. So in terms of what that practically looks like, are you kind of in the physician room or physician workspace and they can come run anything by you?

Dr. Joanne Loethen: Absolutely, yeah. We’re on site, with them and certainly in their initial year, their intern year, as you know, when they’re first starting out, we see all the patients that they see, and then from there it’s just based on, whether they have questions or, have something that they want us to look at, if they’re questioning a diagnosis or management, but they are always talking to us about the patient’s care plan. And then we as faculty also can intervene if we feel that more attention, a given problem is needed.

Dr. Frances Mei Hardin: That’s awesome. And honestly, you know, kudos to you because that’s probably not for the faint of heart, you know, being the attending who needs to balance resident autonomy and learning with, of course, like, really high quality patient care.

Dr. Joanne Loethen: Absolutely. The patient always comes first, but it is an opportunity for the residents to experience some autonomy because essentially, as you know, we’re trying to move them toward independent practice in a transitional, type of environment.

Dr. Frances Mei Hardin: Yeah, that’s really interesting. And it even reminds me of like, one of the models that we had at our VA hospital is that that was a resident run clinic. And so we did have an attending. Of course, they were in the resident workspace and they were available for anything to be run past them. However, even our junior most residents on that team, they did see patients independently, and then they would staff them, really, with the chief resident was kind of the person who would run that clinic or be more available to see patients with them. But so, you know, there’s always interesting variations on these models, and it’s cool to see the variation.

Dr. Joanne Loethen: Yeah, I imagine every specialty is probably different in terms of what their guidelines or their protocols are. certainly you surgeons also have a longer residency as well. And so with just a three year or four year residency for internal medicine and med peds, we think that we should be the ones that they’re checking out to, to see what might, ah, need to be done.

Dr. Frances Mei Hardin: Yeah, that totally makes sense.

What was your experience like choosing to go into medicine at age 29

Well, to jump pretty far back, but to start at the beginning, what was your experience like choosing to go into medicine at age 29 in, you know, really going a non traditional route?

Dr. Joanne Loethen: Yeah, it was definitely a big decision. I, was blessed with great mentors who helped me throughout. a brief story of where I came from is that I was sitting in my chemistry one on one class and hoping to be a physical therapist and undergrad and, physical therapy. It was a miserable chemistry course, and, the professor was brilliant, but I had a hard time following what he was saying. Then I went to my physical therapy orientation and what I was going to take, and I pretty much said, I’m done. I do not need all this science that I’m going to have to do. and it was interesting then fast forward so many years later that I realized that, hey, I actually do want to pursue a career, in healthcare. And being a physician seemed to fit the best with where I wanted my career to go. So it was a big challenge. a lot of things have to be taken into account. Certainly the time commitment, the, rigors of training, which I don’t even think I fully comprehended at the time that I was deciding to go to medical school, as I’m sure most medical students don’t and then, of course, the financial aspect, which is nothing to be, taken, lightly.

Dr. Frances Mei Hardin: Yeah, you cannot shake a stick at the financial aspect, for sure. And it kind of seems like it gets worse every year. You know, it’s so interesting that you did take that non traditional path and, you know, of course, like, work a job for most of your twenties, it sounds like, because I did not know that about you when we first met. But yet you do have this, like, worldliness and perspective that not all doctors have, especially when they just run straight through all their schooling and training. You know, I just think that having that real life experience, having worked other jobs, having played other roles in the healthcare system and things like that, they help you see the picture differently.

Dr. Joanne Loethen: Yeah, it does. I really admire my colleagues who were able to make that decision earlier on in their education. I was just not one of those people. And I am so grateful for actually not doing that because it allowed me to live life and understand those challenges. And then medical school didn’t seem as hard in terms of the organization of time, the commitment of hard work that I had to put. So I found it amazing, to give me some perspective. So.

Dr. Frances Mei Hardin: Yeah. And it always seemed like that in medical school and residency, you kept up a lot of great habits in terms of, like, physical activity and eating really clean. And do you feel like that was just a continuation of things that you’d set up earlier in your twenties?

Dr. Joanne Loethen: Yeah, I think I developed some fortunately good habits, I think, throughout, my pre medical school life, and it was easier to continue those because I was. It was just part of my routine and I was so committed to it. And I also knew, I knew medical school was going to be hard and a lot of hours, and I knew residency was going to be a lot too. definitely my non negotiables were maintaining my fitness and nutrition so that I could actually feel good about myself no matter what residency was going to throw at me. now, that didn’t always work. There are definitely dark days in residency and medical school, but I do think it helped quite a bit.

Dr. Frances Mei Hardin: I love that so much. And, you know, I’m kind of the other end of the spectrum. Never learned to cook until a senior residency, and even then, it’s pretty few and far between. I kind of went into medical school on the granola bar diet, and I carried those habits with me, you know, just eating fig newtons and, like, ruffles most of the time.

If you had to give advice on ways to optimize nutrition for incoming medical students

If you had to give advice on ways to optimize nutrition for incoming medical students or like, a graduating medical student who’s about to be hit with the residency training experience. What do you like to advise people?

Dr. Joanne Loethen: Gosh, that’s a great question. I would say, first and foremost, as, you know, get as much sleep as you can, because whenever we’re all sleep deprived, it definitely does not do well for our willpower and saying no to the cafeteria at 12:00 a.m. so. But I think the most important thing is you have to plan and be organized to do it. it doesn’t take a lot of time once you set up your systems, but it does take some planning. Like, if you don’t want to succumb to the temptations of the cafeteria over lunch hour, whenever that lunch hour might come for you, if it comes at all, then, planning ahead and packing something for lunch that, you know is going to be sustainable. And then also listening to your body, you know, I think we all know what makes us feel good and what makes us feel not so great. and remembering how certain foods make you feel and realizing that, okay, if I want to feel better, I know that these foods, sustain me throughout the day, and they don’t make me crash in the middle of the day or at night. And these are the foods I should be incorporating.

Dr. Frances Mei Hardin: Yeah. Do you have any, like, two or three go to foolproof snacks for the trainee on the move. No pressure.

Dr. Joanne Loethen: I would say, I always got teased kind of in training that I would always tack a salad and I would just, like, load it up. A salad as, like, big as my head. And that always, like, got me through the morning because I knew I was going to go get it. And then, it also sustained me through the afternoon. in terms of snacks, I mean, I think protein shakes are fantastic in the morning because we’re all on the go, or even making a shake the night before, with your favorite fruits and that type of stuff is a good thing to just keep, that’s going to preserve in the fridge, and you can just grab and go. I think that’s the key because most of us want to give as much, get as much sleep as possible.

Dr. Frances Mei Hardin: Yeah.

Dr. Joanne Loethen: So set yourself up for success. Don’t, don’t rely on willpower alone to help you eat better and, do the things you want to do.

Dr. Frances Mei Hardin: No, that’s so perfect. And obviously, I veiled it. I was like, oh, yeah, what would you tell a trainee who didn’t know how to properly get their nutrition in and plan ahead? And I’m like, the person who doesn’t know is me. It’s just me. I’m that fake trainee from the hypothetical scenario. No, I’m just kidding. That’s very helpful. And I really do. I think that physicians who have cracked some of that code in terms of maintaining their non negotiables and being able to carve out time to take care of their bodies and minds, like, that’s awesome. We can all learn so much from you.

Dr. Joanne Loethen: Yeah. I think, again, knowing what is make you feel good and then recognizing that, because otherwise you get into this vicious cycle of, I didn’t sleep last night. I had to wake up at 04:00 a.m. i’m going to eat something that I know isn’t good for me. I’m going to crash in the middle of the day. I’m not going to sleep well again at night because of what I ate that day. And so I think just kind of knowing how your body responds to things totally well.

How can we best educate residents across the country on the hidden curriculum

Dr. Frances Mei Hardin: So to shift into the main topic that we’re here to discuss, there’s just not a huge volume of literature out there on the topic of the hidden curriculum. You know, there is. For instance, I just shared the journal article about hierarchies in the OR, and. And I really love that. That’s from back in 2015 in Canada. But hopefully one day we can more formally build this type of curriculum into medical training. But, you know, my question for you is, how can we best educate residents across the country on the hidden curriculum?

Dr. Joanne Loethen: I think it starts with faculty. I don’t know that you can tell residents what the hidden curriculum is because I don’t think they know it when they’re coming into residency. But if you have programs within your residency that are the residents as teachers, programs where they’re kind of nurturing that. I think building professional skills and reinforcing those in residence, is really important. You know, I was a chief resident, and I loved my first year residents. And they kind of become your kids, right, because you’re owning that group. And the seniors are great because they’ve already been kind of trained in the initial trenches. But as a chief resident, you really get to know the interns that come in during your chief year. But I had to remind myself that, for a lot of them, that’s their first job. So professional skills may have not been taught in medical school. You know, they’re getting their first salary. They are, really learning how to more independently, interact with patients, and not be. Maybe have, direct oversight all the time. By a faculty. And so I think we overlook a lot of those small but very meaningful characteristics and lessons that they are learning every time they’re watching us interact with patients. So.

Dr. Frances Mei Hardin: That’s so true. And building on the fact that this is many people’s first job, it’s like they don’t have often the history of, like, coworker relationships. They don’t know what that looks like, all the time. And so sometimes we see different ways that that plays out in the hospital. Like, it’s a very high, acute, time sensitive, like, critical care situation. And interpersonal effectiveness skills can just fall by the wayside, in part because we’re never formally taught them and people may have not seen them modeled in jobs before.

Dr. Joanne Loethen: Absolutely. I think, you know, the tone we use in our voice, the way we present ourselves, the way we talk with patients, and, you know, what our body position is when we’re talking with them. and then I love that you said, working with coworkers and not just our own physician co workers. Right. Talking about respiratory therapists and nurses and medical assistants who are so vital to the healthcare team. And honestly, we probably do a pretty poor job of helping residents understand exactly what everyone’s role is. We just throw them in, and then we name off someone, and so, and so does that. And so, and so does that, but not really teaching them. they’re all professionals as well, and we’re all trying to work within our abilities.

Dr. Frances Mei Hardin: Absolutely.

What advice would you have to a resident physician who is interested in this topic

What advice would you have to a trainee, like a resident physician who is interested in this topic, and they want to, you know, they want to approach medicine with kind of, like, this team based, very empathetic and kindness forward type of approach. But let’s say that that is not what’s being modeled for them in their department or in their residency program. What do you think are some healthy ways to, like, handle that or navigate it? I mean, it can be really tough if you don’t have, like, a role model who’s modeling good behavior for you.

Dr. Joanne Loethen: Yeah, I think it is identifying the people that you do admire and that maybe you’ve noticed that patients respond to them in a different way, and then thinking about the traits that I want to pick up from that person. You know, we tell interns, internal intern residents, when they’re graduating into their second year, like, progressing into their second year, that toward the end of their intern year, they should be thinking about which seniors they really resonate with and which seniors maybe don’t have traits that they will not carry with them as a senior resident. Because really, when you go into your second year, and then some residencies into your third year, you really become the overseer of the medical team to some degree. And that’s really where you take on those habits of how do I want to talk to patients? How do I want to position myself, how do I want to respond to emails? What is the mood that I want to bring into the workroom? And, those types of things, those little things make a big difference. And then the other thing I would say is, look beyond medicine. We’re not the only customer service industry. and I’m not calling patients customers. There are patients. You know, there’s a lot of analogies between business and, other professions that they’ve mastered this somehow. Right. so there’s a lot of things that we can learn from other industries that I think we kind of get in our silo of medicine, and we are very smart individuals when we get out of medical school. And I think sometimes we take that for granted when it comes to relationship building. How to network, how to market an idea or sell an idea, and just how to carry yourself throughout your workday.

Dr. Frances Mei Hardin: That gets me so excited, because I agree with you, there’s an incredible wealth of knowledge out there. I agree. I do look to the business world.

Two titles that have influenced how I approach interactions have been books

And so two different titles that come to mind where I have been very positively impacted by books that I’ve read, and they’ve affected, you know, they’ve affected who I am as a doctor and. And how I approach all of my interactions with other people, whether they are my patients or they are coworkers or, you know, really all relationships. And so the two titles for me, and I’d love to hear, like, if you have a couple titles that you’ve checked out recently that really resonated with you on this front. But number one, probably talking to strangers, which, you know, that was a huge bestseller, and you’ve probably seen it, in all your bookstore friends. Yeah, yeah, yep. It was just so helpful. It really helps us, like, consider how we approach all of our interactions, not just from the ego, the self, but, like, how other people may be perceiving us, which, again, I know in my medical career, I’ve never received formal training on that yet, you know, on a clinic day, like, I meet 30 new people a day. So it actually, you know, it’s a significant part of my practice, how I am being perceived by others or what type of energy or vocabulary I bring to each interaction. And then my second title would be the charisma myth, which I really loved. And that’s one that a lot of people in the business world and like CEO’s executives use to optimize their charisma. The myth is that you’re just born with it or you aren’t. And so give up. And you know, like if you’re a, ah, quiet, nerdy person in your medical school class, like you’ll just never have charisma. Like, you know, just give up. And I can say as a very nerdy, weird person from my medical school class, like, nope, it is teachable. I haven’t mastered it or anything. But I love that that book has like just a lot of very practical exercises. It has skills laid out, but you can physically go through and you know, do all these exercises as you’re reading it.

Dr. Joanne Loethen: I love those books. I have not read the second one that you named, but definitely talking with strangers or anything, but Malcolm Gladwell, he’s just such a gifted writer. And now podcaster, actually he has a great podcast.

Dr. Frances Mei Hardin: So the charisma myth is by Olivia Fox Caban. And it’s pretty fun. It’s just like a very fun, you know, beach read. It’s a quick thing.

As a physician, how do you teach leadership skills to your residents

So yeah, I’d love to hear your titles. And if you have to look up, if you have to look up.

Dr. Joanne Loethen: No, no, I have my go tos, but they’re actually not recent reads. They are books that I read way before medical school. when I finished my masters and I was doing some health coaching and definitely more of a customer service industry. I always admired people who could network really well and they could strike up a conversation with anyone and I don’t even know, I think I was listening to a radio talk show at the time and this book kept coming up and it was how to win friends and influence people by Jill Carnegie.

Dr. Frances Mei Hardin: Yes.

Dr. Joanne Loethen: I picked it up last year and I try to flip through it at least once a year and it’s amazing how many of the principles still apply. And it’s little things like find something that the other person wants to talk about, use their name. People love to hear their name whenever you’re in conversation. So I recommend that to any medical student or anyone in any business or any industry, actually, I think it’s a great book. And then the other two, I would just give authors because they’re both fantastic, which is Stephen Covey, he wrote, the seven habits of highly affected people. I think my brother gave me that for my college or high school graduation and it was such a great book. that rings true today as well. And he has a lot of different iterations. And then John Maxwell, he, wrote a lot of books on leadership, and, yeah, a lot of how to manage people, how to be a leader. And if you think about it, every physician is a leader of the healthcare team. So I think it is so essential that we’re teaching that early in medical training, as early as medical school.

Dr. Frances Mei Hardin: That’s wonderful. I have to check out John Maxwell. Is that right? He’s the third author listed. Yeah, I absolutely have to check that out. But no, that’s great. And definitely always appreciative of new book recs, especially on these, like, really important topics. And yes, the reality is that as physicians, it is on us to, you know, in our strive to always be the best, like, doctor or surgeon, that we can be kind of hone these skills. So in your capacity, as a teacher, an instructor and role model for your residents, how much do you explicitly talk about anything that falls under the hidden curriculum, or do you just kind of, like, lead by example and it doesn’t come up in much literal conversation?

Dr. Joanne Loethen: Yeah, that’s a really good question. I think I bring it up in terms of if I feel like there was, maybe there was an encounter where the patient wasn’t as open as I thought they could have been, if it’s a sensitive topic or if I just think there’s maybe something deeper. I do like to go back in the room with the resident and just kind of feel out what the patient’s feeling and kind of what their body language is saying. Sometimes I feel like maybe I can help model, first of all, how to build a relationship pretty quickly, within a single encounter, and then also walk the trainee or the resident through that experience as well, and then debrief outside of the room. I probably don’t do it as often as I should, to be honest. but, you were challenging me to do it more often, for sure.

Dr. Frances Mei Hardin: No, that’s great. And leading by example, serving as a really strong role model. Obviously, that’s enormous. We don’t discount that at all.

You talked about the importance of sitting down in a patient’s room

But I do think that it’s interesting, especially because I’ve loved some of your columns that you’ve written. You talked about, for instance, the importance of sitting down in a patient’s room, either on their end of their bed or on a chair or whatever’s available. And I would love if you could kind of speak to that aspect of the hidden curriculum, which is very practical.

Dr. Joanne Loethen: Absolutely. I think we’re taught in general why we need to do that. But it astonishes me in practice how often I see people not sitting down and just getting that eye level with the patient. I even now feel very awkward when I’m standing and the patient sitting. for some reason, there’s not a chair in the room or something. It just feels very strange. I’ve actually gotten into the practice, if I’m working in the hospital, to actually bend down, which is not comfortable, but like, you’re in a squat position, but it makes all the difference. And you can see the patient’s face completely change when you get on their level and they just open up and they’re more free to express what their concerns are and buy into the treatment plan too. I think it just shows this degree of concern that you can’t tell standing up. And then in the, hidden curriculum article, I also talked about asking the patient permission. this is more so in the inpatient environment. But he was a great mentor of mine when I was in medical school. And it was remarkable to me, not that he sat down necessarily, but that he actually asked the patient who was in the room, he didn’t have a chair there to sit on. So the only option was the bed. And before he did that, he asked the patient, is it okay if I sit down on your bed? And he actually called it, ah, your bed. And I think that stuck with me so much. And now when I’m in any patient’s room asking them, can I move your bedside table for you? Can I do certain things to help them feel more at home? Which I know seems so weird. You’ll never feel completely at home at, in the hospital. But I do think it’s important to help patients understand that they have control, some control, as much as we can give them in the hospital and show them some respect for their territory and what’s around them. So that’s an experience in medical school that really stuck out to me, and I really appreciate what the patient’s, What their perspective is from that experience.

Dr. Frances Mei Hardin: Yes, exactly. So asking permission from the patient, I really like that, is something that I have done. Now I’m trying to think, I guess recently, like in the preoperative bay, that’s a good example of a situation where it’s kind of tight quarters. You don’t get your own chair as the surgeon. But, Yeah, sometimes I’ll ask permission to perch. I certainly will not perch without permission. And I do think that it. One thing that helps me is that I just am naturally a person who kind of has a bigger personal space bubble. And so I would not really get into somebody’s space like that without asking permission. But it does even help in clinic and things like that because, well, and you and I are both pretty tall, and so that is part of it, because if somebody is visiting with me in clinic, I won’t stand really close to them, over them, unless I’m doing my exam and need to be, you know, up close for otoscopy and, you know, things like that, the oral pharynx exam. But, like, when we’re having a conversation, I do. I think it’s great for us to be cognizant of some of those body language dynamics and just, how some people may have much bigger personal space bubbles than others.

Dr. Joanne Loethen: Absolutely. It’s as simple as asking them just that you can do an exam. I think we often come at patients without asking, with our stethoscopes or our otoscopes, and we just kind of assume that they’re there. To just accept whatever we’re going to do, whether it be an exam or a question that we’re going to ask them is remarkable. The change in the trust and relationship whenever you simply just ask the patient, do you mind if I do an exam on you now? When, I’m in the hospital, if I go through a history, or if I’m just picking up the patient for that day and kind of recapping, help me understand why you’re here. This is what I understand. Can you correct me if I’ve missed anything? And then once we’re through with that conversation, really just simply pausing and asking them, do you mind if I do an exam now? I think that’s just a huge thing. Rather than just coming at them and assuming, they should just accept whatever you’re going to do to them.

Dr. Frances Mei Hardin: Absolutely. And I don’t know where you start in your exam, like, what’s the first thing that you do then? Or, like, the first point of contact for your exam?

Dr. Joanne Loethen: It depends why they’re there. You know, if it’s a focused visit on knee pain, then we’ll talk first, and then we’ll do the knee exam. But if it’s a annual general physical, we usually start, with your favorite, the ears, and then, it just kind of depends on whatever your system is. I’m sure every physician has a different system so that we remember to hit everything that we need to.

Dr. Frances Mei Hardin: Yeah, that makes sense just from my standpoint, and I’m a general ent so, yeah, like, I I do have to look in everybody’s ears who comes to clinic, you know, unless they’re a, follow up for something else or, you know, a post op. Of course not. But m the vast majority of patients, all new patients, they do get their ears looked at. And, yes, that’s the beginning of mine. But what’s so funny is, like, over my years in training, I have seen people, like, let’s. Let’s consider an alternate situation where somebody doesn’t ask permission, they just start the exam. I’ve seen patients jump out of their chair because they were not expecting it, and somebody just put a speculum in their ear. Like, what? You know, what a creepy sensation. And it would be very startling if someone was not prepared for that to happen. So I agree. The more that we can prepare patients and let them know that we’re looking in the ear, request permission to look in the ear, things like that. You never want to see a patient, like, startled or jump out of the chair because someone is poking them.

Dr. Joanne Loethen: Exactly. And especially being sensitive if they have a, you know, if they have pain somewhere. And that’s why they’re there to see you. If somebody comes into me with knee pain, I definitely want to ask first and also warn them, you know, I’m going to do an exam. I just want you to know it may hurt, but I don’t mean to hurt you. I just need to figure out what’s going on. And do you mind if I do that exam? And also just. I don’t know. I think later, when you’re then talking about treatment options, you’ve already established with the patient that, hey, I’m on your team here. We’re going to figure this out, and you have choices. I’m going to help you understand what those are. And I think it just serves. It helps a lot on the back end when you’re talking about treatment, if you can gain the trust up front.

Dr. Frances Mei Hardin: Absolutely.

Could you talk about specialty disrespect in medical school

So, in terms of another part of the hidden curriculum that I wanted to hit today, could you talk about specialty disrespect? Because this is such a popular topic. You know, every resident I’ve ever spoken to about it, it’s like a light bulb goes off. They’re like, wow, there is a name for this phenomenon that I’ve seen, but, you know, never put words to.

Dr. Joanne Loethen: Yeah, isn’t it funny how we are all on the same page through medical school and we’re buddy buddy and we hang out and we study together, and then somehow, immediately when we walk across the aisle or across the stage at graduation. Immediately we go into our own silos, and somehow we’re on different teams. Just fascinates me. And I see this a lot from, every level of training, including physicians, where it’s not an intentional slight, but it’s just enough of a tone or a one word or, just something that suggests that one specialty isn’t worth more than another. And it’s really frustrating. And I think we’re cannibalizing ourselves when we do that, and then it just furthers the silos, and then we’re all frustrated because we don’t know who we’re referring to and, who’s who in our organizations because we now have these walls built up, around that.

Dr. Frances Mei Hardin: Absolutely. To use the definition here, you know, specialty disrespect is the phenomenon of dismissing skill and expertise of other specialties with verbal sites, over the phone, on rounds, and via passive aggressive comments in the EMR. So I liked these examples of saying, call medicine and make them do it. I certainly, as a surgeon, you do hear that on rounds and things like that, or comments like, how did the ED miss this? And I really did. Like, You know, there was a 2020 survey from Georgetown University where medical students were surveyed. 31% stated that comments of specialty disrespect affected their career decisions, and 21% said that such comments affected team dynamics in hospitals. There was also that University of Washington study from 2019 by Alston et al, where 80% of M M three and M m four students experience specialty disrespect in their learning environment. And so I love that because, you know, even as I said in the intro with that journal article, is that people tend to not want to believe or see things until they see it in an academic journal article. So it’s awesome to see, like, a little bit of this in the literature proven, even though, again, we do all innately know it and we’ve seen it. One point that I love to make, especially when I’m talking to, like, the next generation, like, if I could give advice to premeds, medical students, residents, anybody, my advice would be, do what you want. Because this issue of specialty disrespect, yes, we should do everything that we can to address it, not perpetuate it, you know, broadly end that cycle, and basically unsilo, like, what doctor Loethen was referring to. But in the meantime, like, let’s say that you’re making your decision now, and you’re like, well, I want respect. I want to be, you know, I want to be one of these doctors who’s, like, higher up on the food chain in the hospital. I don’t want people disrespecting me in the hospital. You make your choice. Well, guess what? I can definitely say that the issue of specialty disrespect and having witnessed it and things like that during my education did affect my decision, and, you know, I chose to go into ent. But what’s so funny is, you know, this never ends, and the goalposts will always move, because as a general Ent, somebody who chose not to do a fellowship, for instance, I certainly get demeaning comments about, like, my limited specialization, and, you know, it’s just. It’s, It’s funny when you think about it, that there are people out there who would take the stance, like, why even bother going to college if you’re just gonna phone it in and become a general ent and you’re just gonna do tubes and tonsils? Like, that’s embarrassing. That’s embarrassing for your life and soul. And so it’s a great reminder that you can’t please everyone unless you maybe spend your entire life and career just doing fellowship after fellowship, and then you’re maybe the only pediatric, double general, colorectal, neurosurgeon, vascular surgeon out there, and then maybe you can be disrespectful to everyone else. Obviously, I would not recommend that route.

Dr. Joanne Loethen: Yeah, it’s, I think you hit so many things on the head where it’s. I think it starts with the stereotypes that we give medical students when we’re talking about specialties and we talk about, you know, what this specialty is like and then what that specialties like, and you can’t go into that specialty. You’d never fit in there, you know, and that type of thing. And are the stereotypes true? Maybe to some degree, but they also create these biases. And then anytime you see, you know, a certain specialty that’s acting like you think they should, it’s feeding that bias, and you fail to acknowledge whenever that members of that specialty aren’t doing those things. And so it just creates this vicious cycle, and it just further splits us up. I wonder if part of this issue is, you know, oftentimes we’re always just talking on the phone. specifically in residency, when you’re calling the console, sometimes now you don’t even have to call. You just put in an order, and it just. There’s no personal interaction at all. I think also there’s not a lot of overlap of our work environments outside of calling for a consult or asking for a curbside, because we don’t work in the same work rooms. You know, if you have time outside of your clinical duties, then you’re probably hanging out with your own specialty. You’re not engaging with other specialties. There’s not really an incentive for programs, for GME programs to help residents be more collegial and work together. so I think the responsibility is probably on us to help nurture that and feed that and then also just call it out. You know, call out whenever we see some disrespect from someone else. It’s not that we necessarily, have to completely disagree with them or that we do disagree with them sometimes it’s just the way they approach the question that makes us angry about it. And learning those communication skills with other specialties or disciplines, I think is so important and understand everybody’s expertise. Right. I’m not going to expect you to detect a heart murmur, and so, you know, I’m not going to, you know, throw you under the bus for missing something there. I know that your expertise is ears, nose and throats, and that’s what you do. And if I have a problem, if it’s beyond my expertise, then I should welcome your collaboration and, hopefully you would welcome my referral to you and that type of thing. So it’s all this relationship building I think we’re missing.

Dr. Frances Mei Hardin: Yeah. And I mean, I’d love to hear if you have any ideas about how we could try to promote, like, even GME type of sponsored events at an institution that would, like, help break down some of those walls and maybe like, give incentive for different programs to socialize with one another. But it’s so funny because I totally agree with you about how we just take it situation by situation, but one that comes up for, like, our younger surgeons that I do feel like I used to do some teaching on by the time that, you know, I was a chief is the middle of the night consult, which is so funny. Like, you know, so when you are taking junior call on a surgical service, of course, like, there are going to be those one or two or 230 or 03:00 a.m. pretty brutal consults, you know, because you went to bed late, presumably seeing consults, and, you know, you got to be up early to round. And so sometimes it will hit right in that, like, couple hour window that you had. But what was always really foreign to me and generally unhelpful is this sense that the consultant resident would pick up the phone. And, you know, the Ed provider would be like, hey, this is what we’ve got. We wanted to ask you. Hey, can you come? Like, look at this. Perry tonsiller abscess. Right? And that, the consultant or surgeon would yell at them. They would be mad at them. They would. They would respond as if, like, you had personally victimized me and my family. And it’s so funny because even when I was going through it and I was burnt out and I was exhausted, I was like, I’m sure this person doesn’t want to be calling me and waking me up, you know, like, just that understanding, because we all have been that other person. Like, I fully remember being an intern in the Ed and calling these consults, and I was like, I’m afraid, like, I don’t want to be calling you any more than you want me to not be calling you, you know what I mean? And it’s just kind of that ability to maybe put yourself in the consulting physicians or the consulting providers shoes, could be very beneficial, I think, in not having, like, a reaction to that phone call that does not behoove you.

The midnight consult call comes from a consultant’s perspective, right

Dr. Joanne Loethen: Yeah, the midnight consult call, that’s a good one. so many layers to that. I think. I, think first it comes from our perspective of, like, if you’re the consultant, you have to say to yourself, hey, somebody’s reaching out to me for help. Like they’re this. Whatever this is. Even if to me, it seems like such a simple thing. You know, we would, We would kind of get worked up about orthopedics admitting somebody for, you know, a femur fracture, who was completely healthy, but they had hypothyroidism, and they were on a stable dose of, ewothyroxine, and they would consult medicine and is that kind of like an overstep? Sure. But at the same time, they aren’t trained to treat thyroid. So to me, I’m thinking, hey, I can help you. I’m more than happy to come see this patient. And if I really think this is a recurring problem, and I think you guys could maybe handle it, maybe we develop a protocol to help you out, you know? And then if it falls outside the protocol, give me a call. But I’m always happy to help you. Right? I think that’s it.

Avoid saying you’re sorry when you’re the one calling

I think you hit on something else where it’s, like, the middle of the night and the consultant picks up and they’re angry. I think you may have experienced this, too, but, avoid saying you’re sorry when you’re the one calling. So, I think often I hear residents, immediately, as soon as so and so picks up the phone for the console, they’re like, I’m so sorry to bother you. And I say, don’t say sorry. That’s what they’re there for. Reframe, it and say, thank you so much for taking my call. That shift in language helps so much because then you’re kind of putting it back on them to be like, oh, okay, they need me. Right? Instead of, oh, they’re doing something wrong. They’re apologizing. No, it’s, hey, thank you so much for helping me out. this is a little outside my scope here. I need some help.

Dr. Frances Mei Hardin: That’s true. That’s a great point. And, yeah, so, I mean, there’s so many of these, like, million little tips and tricks for us to, I think, conduct our business as physicians better. And so thank you so much for all that you do to be a phenomenal role model to the next generation of, physicians, you know, at your institution, but then also the work that you do, like, nationally and at the advocacy level to kind of make medical education a better place.

Dr. Joanne Loethen: I try. I don’t know that I’m making much headway, but there are a lot of smart people working on this issue, and I’m confident that eventually we’ll see the light at the end of the tape tunnel and, hopefully get there. So.

So the last question that I wanted to ask you is, do you believe in karma

Dr. Frances Mei Hardin: So the last question that I wanted to ask you is, do you believe in karma?

Dr. Joanne Loethen: Do I believe in karma, like, something bad happening because I did something to.

Dr. Frances Mei Hardin: Beat it up because of something good? Any version of karma. And people do have their own definitions of karma. Some people are like, I believe in this specific definition.

Dr. Joanne Loethen: I do. I think I do. I think I, you know, believe in karma. And I think it also helps us hold ourselves to higher standards when we think somebody else is watching. And, hey, I’m gonna treat other people right because I expect the same from them. And. And so I do agree. I do believe in some karma.

Dr. Frances Mei Hardin: Perfect. Great. Well, thank you again for joining me today, doctor Loethen. It is always such a pleasure to chat with and learn from you.

Frances May: I love what you’re doing with this podcast

Dr. Joanne Loethen: Thank you so much, Frances. Me, this has been such a, pleasure to do and so exciting. And I love what you’re doing with this podcast, and your website is phenomenal. So, thank you for what you’re doing, because I really think you are showing residents that there is a light, and we can make this experience a little bit more tolerable, even though it’s hard, and it’s always going to be hard, and it’s supposed to be, It doesn’t need to be torture. So thank you for what you’re doing.

Dr. Frances Mei Hardin: Next week, we will have Doctor Noam Rader come on and discuss her career as a family medicine physician and lifestyle influencer. Follow me on Instagram at Francesmay, Md. And rethinking residency visit my website,, to learn more about resident physician stories and ways that residents can most effectively navigate the game of residency. I cannot wait to connect with you on the next episode of Promising Young Surgeon.