For the Office-based Teacher of Family Medicine

Doctor Lounge Talk
Paul J. Munson, EdD; Judy S. Gary MEd

Among Colleagues
When you’re in the doctors’ lounge talking with colleagues, what do you talk about? Is it sharing patients’ stories or perhaps seeking advice on a patient case? Or, is it conversation about life outside of medicine, like recent family events, financial ventures, a recent vacation, your favorite sports team, a movie or a play you just attended, or the latest joke? What about the stresses of medical practice, like HMOs, reimbursement, and annoying patients, etc?

With Students
When you’re teaching students, what do you talk about? Do you discuss the students’ learning needs, talk with them about the patients they’ve just seen, and query them about their logic? What do you say to students to encourage and support them? Do you discuss what family practice is like as a career—the joys, the challenges? Do you compare notes about the rigors of medical school? Do you discuss how students can meet their personal and professional needs in relation to medicine? You probably do most or all of these things over time. However, there is a tendency for some preceptors to bring “doctor lounge” talk into the student-preceptor transaction. What is the potential impact when that occurs?

Illustration: The Challenging Morning
The last several patients had important issues that took longer than expected, putting you behind schedule. Feeling frustrated, you express how you just spent the morning with patients for whom you won’t be adequately reimbursed. You say, “Well, I hope this afternoon is more lucrative. I’ve got to make up for this morning since I can’t bill for all of the advice I gave.”

A Colleague’s Perception
While grabbing lunch in the staff lounge, your associate says, “Yeah, I’ve had mornings like that. I wish the health care system would acknowledge the kind of role we play in patient care and provide more appropriate reimbursement for all of our services.” Since colleagues share a similar frame of reference, they are likely to understand and perhaps even feel as you do at times. Colleagues understand the intricacies of medical practice and can put your comments into perspective. Students might not be able to put your frustrations in context. Doctor Lounge Talk Paul J. Munson, EdD; Judy S. Gary, MEdFrom the Department of Family Practice, Virginia Commonwealth University.

A Third-year Student’s Perception (1-month Rotation)
A third-year student hears the same comment and thinks, “I know it was a rough morning, and I’m not sure I’m comfortable with Dr X’s comment, but all in all, in the 2 weeks I’ve been here, I know there are mostly good days and a few bad days. Guess this is one of those bad days.” By third year, this student most likely has developed some understanding of practice management (eg, overhead costs, time pressures, and reimbursement, etc), especially if it is one of the student’s later rotations. The student is probably able to put your comment in perspective. Other students observing the same incident could be wondering if this preceptor makes a decent living and is satisfied with family practice as a career. What potential impact might the same comment make on a student during the first few days of his/her rotation with you?

A First-year Student’s Perception (Half Day, Twice a Month Preceptorship)
Hearing the comment, the student thinks to himself/herself, “My preceptor seems really impatient with patients and focused on money. There goes my image of the caring family physician.” First- and second-year students usually visit their preceptors on a more episodic basis—once or twice a month. With even the most experienced preceptor and most enthusiastic student, it generally takes several visits for genuine rapport to build. Most first- and second-year students have little knowledge of the business of medicine. They also lack the understanding of the breadth of medical practice. Comments like this may leave the impression that you care more for making money than for your patients. That, coupled with the fact that they don’t see how you approach your work day to day may result in their thinking that you don’t even enjoy your chosen profession. Since most students wouldn’t feel comfortable exploring such a comment with their preceptor, what do the students do with their impressions? How do you help students reconcile their idealized notions of family practice with the realities of medical practice without dampening their enthusiasm?

Tips
1. Keep in mind the student’s level of development when deciding what you want to disclose. Are students capable of seeing the bigger picture, or are they seeing your world through a peep hole? The learning task may be to help them develop a broader view—to open the door. Carefully choose topics that move the student along the learning continuum—from peephole to open door. 2. Avoid using your student as a therapist substitute. It is tempting for some preceptors, especially if they feel unsupported, to unload on students with their personal stresses and professional frustrations. In most cases, students have difficulty putting your concerns in perspective and feel overwhelmed with the obligation to listen and learn. 3. When referring to patients and staff, be conscious of the ways in which you characterize them. Students may have difficulty interpreting your references, particularly as they relate to cultural differences. 4. Teach students only if you are satisfied with your career. Students need and want an honest perspective about family practice and can hear and benefit from a balanced view of the joys and challenges of being a family physician. 5. Be congruent. If you find that you have expressed your frustrations, help your student understand the big picture in relation to the event of the day.

Summary
The discussions that take place in the doctor’s lounge are essential to the well-being of the preceptor. Doctor lounge talk should be filtered for students with their level of development in mind. Corresponding Author: Address correspondence to Dr Munson, Virginia Commonwealth University, School of Medicine, MCV Station Box 251, Richmond, VA 23298-0251. 804-828-9779. Fax: 804-828-5856. pmunson@hsc.vcu.edu.