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After the Match: The Crab Bucket

Cook, Thomas MD

doi: 10.1097/01.EEM.0000459714.50032.b6
After the Match

Dr. Cookis the program director of the emergency medicine residency at Palmetto Health Richland in Columbia, SC. He is also the founder of 3rd Rock Ultrasound (http://emergencyultrasound.com). Friend him atwww.facebook.com/3rdRockUltrasound, follow him @3rdRockUS, and read his past columns athttp://bit.ly/CookCollection.

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Emergency medicine residents meet with their program director for evaluation twice every year. Let's be honest; no one likes this. Who wants to walk into a meeting with her boss to review what she is not doing right? It creates a lot of anxiety, usually followed by relief and often disappointment, second-guessing, and more anxiety in a business known for incredibly stressful situations.

Our residents are evaluated by faculty and their peers (the other residents) and a few ED nurses. All evaluations are presented to each resident anonymously.

Naturally, residents cringe at any criticism of their performance. They have invested an enormous amount of time and money to get to this point in their lives, and despite easily deflecting insults by patients, they perseverate on even subtle criticism in evaluations, even when lumped into a large collection of comments that praise nearly every element of their being. In short, they are a bit sensitive.

It is interesting to note which group criticizes and compliments the most. Nurses generally tend to be more critical, attendings fairly balanced, and peers tend to heap loving praise on their fellow combatants. That nurses might want to take a shot at the youngsters who arrive knowing nothing and leave with huge salaries is not surprising, but I have found their comments to be insightful, especially in helping me identify specific residents who have problems interacting with staff and patients. Attendings' evaluations are usually accurate about a resident's strengths and weaknesses.

Peer evaluation scores, however, are typically 20 to 40 percent better than those by faculty and nurses. Perhaps it is wishful thinking on their part that by being nice to their classmates on evaluations will get them treated likewise. But this comes with a catch. If a resident moves too far from what is considered appropriate behavior, their peers will seemingly come from out of nowhere, band together, and punish him. The effect on the resident is akin to being hit in the head with a sledgehammer. They are broken to bits and often in tears. Welcome to the crab bucket.

When you boil a pot of crabs, the few that manage to grab the rim in an effort to escape are pulled back down by the others. This is sometimes used to describe how members of a disadvantaged group seeking to leave through education and hard work are discouraged by others in their group and even pulled back to “where they belong.” The crab bucket actually has a positive effect on residents, however. They are pulling someone back into the group not to cause failure but to join them in success.

Ask any resident, and they will tell you they universally hate their colleagues for showing up late, not picking their share of charts, and making sloppy turnovers at change of shift. Do any of these enough, and the banter in the residents lounge is how you are becoming “a problem.” It might take a while, but when the tipping point is reached, it creates an evaluation tsunami, and the resident gets pounded.

Fortunately, this problem is easy to fix, and even the most dysfunctional resident can get back into the good graces of his brethren by working on these issues. But just as important, the resident learns that peer relationships are critical to success. Residents only have to fear what their attendings think of them for a mere 1,000 days. Peer impressions last decades, and you will find yourself unhappy at work and regularly changing jobs if you do not play well with others.

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