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Residency Insight -- A PRESENT Podiatry eZine

Volume 4 - Issue 11

Robert Frykberg,
DPM, MPH
PRESENT Editor,
Diabetic Limb Salvage

Diligence – the IT Factor for Residents

I am constantly learning from all the residents that I've worked with over these many years. Residents do have a way of keeping us older attendings on our feet (so to speak) — your level of knowledge and experience is so much greater than that which we possessed at your level of training. Nonetheless, every Residency Director and faculty attending observes a great deal about each individual trainee that comes under our supervision. While you may think we just don't get it or wonder about the level of our knowledge, we certainly do know what makes a good resident and separates the good from the bad.

In the last 33 years, I estimate that I have participated in the training of at least 66 Podiatry residents (some of you reading this column have had that dubious pleasure). As I mentioned above, some were good, some were bad, some were mediocre, and some were outstanding. Many are very memorable, while others might have long faded from my memory over the years, especially if they do not regularly attend national or regional conferences. Some have become leaders in their own regard, taking on the mantle of directors or faculty themselves. Others have become noted authors and highly respected DPMs in their own rights. But the question remains, "what is THE factor that makes a resident a good resident?" It is not just brains, the ability to memorize or even to process what is memorized, although that helps a great deal. We have all known very smart people that, for some reason, just didn't quite live up to our expectations. And to the contrary, we have all known mediocre students who, when given the chance, became superlative residents and clinicians. So what is that essential factor? Diligence certainly comes to mind. My dictionary defines this trait as "assiduousness" — one who displays persistent effort, conscientiousness, and thoroughness. I think these various synonyms really capture the essence of a successful resident in large measure.

Diligence = persistent effort, conscientiousness, and thoroughness. I think these various synonyms really capture the essence of a successful resident in large measure

Here's an Example....

The practice of Medicine, Surgery, and Podiatry have all become very complex over the last three decades. While head knowledge is, of course, essential in mastering these disciplines, there is much more to the making of a good resident. Assiduity is a wonderful term to become familiar with- and a wonderful trait to possess. An example might be as simple as the patient who shows up to clinic on a Friday afternoon just before quitting time. The patient has a several day history of a red, swollen foot, but no pain due to diabetic neuropathy and no obvious deformity. The patient may or may not have symptoms of malaise and may not even have a fever. There might be some mild swelling in the leg as well, but no history of injury related to you. You think, ah, this has to be a diabetic foot infection but there are no signs of penetrating injury and no open wounds. There is no crepitance nor lymphangitis — but you are suspicious. You had to call to radiology to get them to fit this patient in for foot films right away, in order to rule out any subcutaneous gas, foreign bodies, Charcot arthropathy, or other sign of pathology. None were found. You were also wishing to rule out a DVT in the leg of this relatively sedentary patient. Venous ultrasound was negative (you called the vascular lab before they left for the day). Similarly you know that lab tests need to be ordered quickly to ascertain the nature of the problem. You need to determine whether this patient needs to be admitted before your attendings are gone for the day (and weekend). But something is still bothering you about the patient’s history, poor as it was. He was taking some pills for blood pressure (his only other current medical issue), but couldn’t remember what they were. You suddenly wondered, could this just be gout without such a prior history? Then you called the patient’s wife at home, who told you that he was taking a “water pill” (furosemide). In your orders for lab studies, you not only asked for the routine CBC with differential, but also a sedimentation rate and a serum uric acid following your hunch that this might be an acute onset of gout. The only abnormality was an elevated uric acid, thus making the diagnosis of gout. A prescription for uricosurics and a strong NSAID was given, as well as an offloading boot and an appointment to return the following Monday to insure that he was better. The following Monday, all signs of acute inflammation had been resolved and you personally called his primary physician to insure that he was seen for follow up and initiation of allopurinol therapy.

A Good Resident is Engaged in Patient Care, S/he Lives it

The good resident looks for the Zebras amidst the herd of Horses, and sweats out the surveillance process

I think a case scenario such as this demonstrates a resident who is engaged in the diagnosis, management, and follow- up of his patient. It took a little more effort at the end of the day to obtain all the required diagnostic studies and the essential call to the patient’s wife to confirm an educated hunch that the problem might not be the one usually expected. The diligence of the resident in this regard is self evident and is commendable. The good resident looks for the Zebras amidst the herd of Horses, and sweats out the surveillance process. Wouldn’t it have been far easier to prescribe an antibiotic and instruct the patient to return in a few days? Yes, it would, but this course would not have been best for the patient. The assiduity of the resident in getting to the bottom of the patient’s problem and ferreting out the details has distinguished him/her from many others who would not necessarily display the level of care and concern exhibited in this case.

I see many other similar examples carried out on a regular basis by those exemplary residents who go the extra distance to do what is necessary to get the job done for their patients. Their diligence sets them apart from others – and it is always noticed by their Directors. It is what makes them good doctors.

Think about this resident trait and let us know your thoughts — and I always welcome topic suggestions for future issues.