Notes To My Residents: #2 - Style

Think About What Suits You

I just had my residency graduation ceremony this past weekend! As is tradition, my program director comes up and gives a speech about each of us; he likes to try and capture some unique aspect of a particular resident. Are they enigmatic? A (worryingly) hard worker? Bewilderingly well read? Somehow attracted to the nightmare task that is putting together rotation schedules for the entire residency?

For me, it was about how annoyingly independent I am.¹ In particular, my PD spent a long time telling the entire room about the nonstandard photo that I had chosen for my residency application and how it caused him to worry that I might be a bit too much of a rebel. It was this one:

Sorry I have a congenital abnormality where all I can do is smirk when I am told to smile for the camera. I know it makes me look off-puttingly smug and have been working hard to rectify the situation in recent photos. Thank you for your support in these trying times.

He embellished how casual I looked for the sake of the story — the caricature is part of the joke — but it’s certainly not the plain/off white-background face-on headshot that applicants typically use. This photo is, in fact, a picture from my wedding. I chose it because I didn’t have a professional headshot and frankly couldn’t be arsed to put on a suit and tie for the sake of a 300x300 pixel image. Also, if anywhere was pretentious enough to take me out of the running because my background was of a brick wall instead of an off-white wall and my tie was slightly loosened, it was probably better that I didn’t go there at all. (Dropping me for the pretentious smirk would’ve been fair, though).

Anyway, after the speeches wrapped up, I told my PD that I didn’t realize just how much that picture influenced his perception of me. He just chucked and said “Yeah, but that ‘young college professor’ style suits you perfectly. You make it work for yourself.”

Why am I telling you this story? Well, I thought that this would be a good chance to talk about your style as a clinician.

My general impression is that most residents initially either fall into a style unconsciously based on their personality, or by picking up the style of whatever attending they’ve been working with most recently. I fell into the former category. There’s nothing wrong with either of these things per se, but I think that most of us would benefit from thinking about our clinical style a little more deliberately. If you’re one of those rare residents who are birthed from the womb of medical school as a resident with a fully formed clinical style, well, I’m sure your alma mater is very proud of you, but I still think you should think about it!

What do I mean when I say style? Good question! Style can be separated into two overlapping categories; professional-facing and patient-facing. In both cases I’m broadly talking about how you as a physician choose to present yourself to your patients/colleagues and interact with them, within the strictures of your professional relationship. There are many elements of a professional style: dress, demeanor, office decoration, emotionality, strictness, just to name a few.

I’m not really going to talk about professional-facing style in this essay, because I think I need some time as an attending to have much to say on that topic. That’s not to say that you can’t start to develop it in some sense as a resident, but I feel like I only really got a taste of doing so in some of my PGY-4 administrative duties and when I was moonlighting. In the meantime, let me describe some aspects of my patient-facing style along some of these dimensions so you can get more of a feel for what I mean:

I’m not the sort of doc who wears a suit or a tie. I wouldn’t be caught dead in a white coat. I wear slacks, a collared shirt, and sneakers. I don’t regularly iron my shirts or have my clothing dry-cleaned. (Also, I think short sleeved button-ups are totally fair game when its hot outside.)

My office where I see outpatients is clean and semi-organized. I have books on my shelves that are the sort of thing that you would expect in a psychiatrist’s office (Maudsley’s, a DSM-V reference manual) and some things that you wouldn’t (a collection of SciFi short stories, the print version of Asterisk magazine). Other things on my shelves include my diploma, a teaching award, a Gunpla from The Witch From Mercury that I assembled myself,² artwork from my wife on the walls, origami art from one of my co-residents, a couple of plants, and other assorted knickknacks. Here it is:

My Office

I don’t sit behind a desk or type while I work (I mean, I couldn’t even if I wanted to, but I don’t and I wouldn’t) and I don’t go out of my way to look very prim or proper when I talk to my patients. I slouch, I adjust my position on my chair, etc.

When I talk to patients, I’m fairly casual. I introduce myself as Dr. Wendel, but if they choose to call me Dr. Nils or even just use my first name I don’t really correct them. I use their first names unless they ask me to use something else. I try to talk to them like I would anyone else. I don’t curse excessively, but I will for emphasis, particularly if a patient isn’t shy about cursing themselves. I joke with my patients, when appropriate, particularly with the ones that tend to be overly serious and sarcastic. I go out of my way to tell patients when I am confused or uncertain about something.

I am relatively expressive. I generally do not try and hide my feelings from my patients, though I am very even-keeled as baseline so I am not really afraid of over-emoting. If something about our conversation moves me to tears, so be it. If I find them exasperating, I’ll tell them.

You get the idea.

Surprise, It’s An Essay About Authenticity

If you read my first Notes To My Residents, you will probably not be surprised to hear that I think it’s important that your style feels authentic. By that I mean that you and your patients feel that you are showing them a side of yourself that is not pretense, but a reflection of who you are as an individual.

I think that it’s very easy for medical students and residents to get in their heads that there is a certain set of ways that a doctor is “supposed to be” and then try and mold themselves into that sort of person. While it’s true that there are certain boundaries that need to be obeyed — you can’t literally “just be yourself” — there is much more flexibility than you might think.

“But Dr. Wendel, what if I’m actually and awkward and anxious person who makes bad jokes? Surely I need to hide that from my patients, right?”

Mmm, not really.

There was one attending I worked with who I don’t think was what most people have in mind when they think of the “ideal” physician. He was nervous, disorganized, made bad jokes with patients, and could be pretty awkward at times! With me, he often seemed uncertain and a bit bewildered. He also worked with an extremely challenging patient population: individuals with eating disorders who required an inpatient level of care. These are not generally the sorts of people that will give their doctors an easy time. The first time I met him I remember thinking “Oh my god, I’m just going to watch this guy’s patients eat him alive, aren’t I?”

The things that you would assume would really torpedo his patients’ confidence in him: his outward nervousness, disorganization, awkward jokes, verbal slip-ups… they really just didn’t seem to matter. His patients genuinely liked and trusted him. They greeted him warmly, thanked him for his help, took his advice seriously, showed up to his groups, and generally seemed to understand that he really did care about them. When I would meet with them independently, they would often comment on how much they appreciated him and were grateful for his care.

Some Things To Think About

There are many, many details and nuances that I could go into, but I’m trying to keep this piece on the shorter side so I’ll just lightly touch on some things to keep in mind.

Different styles expose you to different difficulties: people with casual styles need to be more attentive to boundaries, or your professional relationship might start looking not so professional. Prim-and-proper styles risk coming off as cold and distant.

The culture of where you work will shift the limits of the range of styles that are considered “acceptable.” This is one of the realities of working with groups of people. Also be mindful of how the cultural norm of your location shifts patient perception. If everyone you work with typically wears a jacket and tie (or… whatever the female equivalent is) and you dress more like me, your patients will almost certainly notice and it will alter their impression of you (for better or worse).

Finally, don’t get too caught up in having a single style as opposed to developing a repertoire. Sure, that repertoire will mostly be in a particular range on the spectrum of style, but you will need flexibility to best orient yourself towards your patients.

1. I annoy myself, to be honest.

2. Anime is cool now, didn’t you know?