In Pursuit of Excellence (Excellence Everywhere)

Hi everyone:

I’m nearing the end of letter writing season. By tomorrow night, I plan to post 32 letters of recommendation for residents applying to fellowship.

These letters practically write themselves. Large parts include quotes from faculty and peers, lauding residents’ talents, accomplishments, and contributions.

Excellence is not a mystery: it emerges from hard work, study, teamwork, emotional intelligence, and commitment to patient welfare. In today’s installment of “In Pursuit of Excellence,” I want to share some of the quotes I’ll be including in my letters of recommendation. I’ve deleted names, but trust me, these comments reflect the performance of practically all our residents:

• Commitment to Learning
• Fund of knowledge: “He had the best cardiology fund of knowledge of any intern I've worked with since coming to Yale. He quoted original research when appropriate and answered questions I typically reserve for cardiology fellows.”
• Curiosity: “He encouraged me to be curious, to ask questions and always practice evidence-based medicine.”
• Always learning: “Despite her excellent knowledge and skill in medicine, she is always poised to learn more and actively seeks knowledge independently; it is obvious that she reads about her patients' diagnosis and management.”
• Always growing: “She enthusiastically seeks and incorporates feedback.”
• Constant Teaching:
• Passion for education: “He is an amazing resident and a pleasure to work with. He stayed up with me the whole night, which is neither common nor required of the senior resident, but he did so because of his passion for medicine and his desire to teach and learn.”
• Patience with learners: “She started off by telling me that ‘no question is too small’ which immediately made me feel comfortable as a brand new intern.”
• Writing Notes:
• Progress notes and H&Ps: “Progress and HPI notes were thorough, accurate, and clearly provided her clinical reasoning in an organized and logical manner. I could already tell from her daily presentations and notes she has a sense for both the big picture in clinical course, but aware of the fine details in care.”
• Transfer note: “She wrote transfer notes that were incredible.”
• Discharge summaries: “Her discharge summaries clearly and concisely summarized the hospital course.
• Showing initiative
• Thinking independently: “She tenaciously assesses and re-assesses her patients' statuses, never becoming complacent that everything is known. However, and incredibly importantly, she also demonstrates an appropriate ability to de-escalate or withhold interventions that may have more risk than benefit. Rather than being a rote "do-er," she actively weighs risks and benefits to inform her medical decisions.”
• Proactive: “By the time I came in for rounds she had already put in all the necessary orders and talked to all the consultants. She was proactive in following everything up and her plans were always thorough and complete.”
• Thinking ahead: “He cares deeply, and I appreciated he always made sure to have discharge summaries completed for patients who were going to be leaving on his day off.”
• Patients first
• Safe transitions: “She sent me sign out on my patients that was extremely thorough.”
• Details count: “She consistently performed detailed chart review, thorough histories/physical exams, and presented in an organized manner. She not only followed up on the patients she was following, but also took the time to review studies/results for all of the patients on our service.”
• Seeing the big picture: “I was truly impressed when she also recognized the poor prognosis of a 94 year old patient on dialysis when he was admitted for new A Fib with RVR and had a family goals of care conversation right in the VA ED (on a rather busy admit day) and transitioned him to hospice seamlessly the same day.”
• More on seeing the big picture: “We had a conversation that I found extremely meaningful on the difficult question of ‘How do I know when a patient won't be able to recover from critical illness, and it's time to recommend comfort measures?’”
• Complete commitment: "He was easily one of the most conscientious residents that I've ever worked with. I was incredibly impressed with his dedication and compassion for his patients. One patient in particularly was incredibly ill, and I remember he stood next to her room all day with his mobile computer. Nothing was going to move him away from her.”
• Patient advocate: “She was also a ceaseless advocate for the patients on our service. There was one patient in particular who had turned into a dispo rock, but she would still try to actively follow through on issues with him to ensure that pain was well controlled or that he was getting hearing aids.”
• Connecting with patients: “His ability to connect with patients is exceptional; he is incredibly attentive to their psychosocial (and obviously the biomedical) needs; the way his patients respond to him is evident by the how they all know him by name, have written him thank you cards on our rotation, and want confirmation from him before agreeing to procedures/treatments. I was humbled to be his resident and to learn from him.”
• Communication
• Communicating with the team: “She was also excellent in closed-loop communication with me, with the rest of the team, and with the other hospital staff.”
• Communicating with families: “Excellent communication with patients and families; minimal jargon; would go to the bedside multiple times per day to speak to patients who were having a tough time or to answer questions.”
• Communicating with compassion: “I learned a lot from our family meetings; he has a real talent for speaking honestly and compassionately to patients and their families about really difficult subjects. I observed him expertly and carefully discuss prognosis and goals of care with a patient with very advanced cancer; per the patient, this was the first truly honest conversation that had occurred with a doctor.”
• More communicating with compassion: “She handled a very sad, very difficult service with profound grace. Her maturity in family interactions was quite impressive and far beyond what I would have expected for someone at her level of training.”
• Above and beyond:
• Getting the diagnosis: “We had one admission for ‘extended colonoscopy prep’ but he was able to identify several other important issues. He found that the patient had an IVC filter which was forgotten about. We had another patient admitted for psych issues who was incidentally found to have a high lactate. Thanks to his thoroughness and thoughtfulness, we identified that patient was actually having mesenteric angina and that the differential for his symptoms actually needed to be much broader than ‘type b lactic acidosis.’"
• Getting medications: “He is a determined, compassionate advocate for his patients. For instance, we had one patient who was immunocompromised due to recent chemo for DLBCL who was admitted for persistent COVID infection and hypoxemia. He went out of his way trying to get the patient bebtelovimab -- a therapy that was not available inpatient at the VA, but was recommended by the ID team. He spoke with our pharmacy colleagues; looked into applying for an Emergency Investigational New Drug application through the FDA; and even called the pharmaceutical manufacturing company, Lilly, and spoke to their representative to try to acquire the drug.
• Going the diagnosis and the medication: “On Sunday morning rounds we were faced with a rare occurrence of possible drug-induced TMA in a patient with multiple myeloma. While we rounded with the sister team, he searched the literature and presented his findings to the renal consultants and us, allowing us to obtain the complement 5a inhibitor eculizumab the same day.”
• Getting ice cream: “She goes above and beyond for her patients…Here are some examples - when a patient was admitted for failure to thrive and was craving ice cream, she bought ice cream from the cafeteria and gifted it to her patient, who was so grateful. She nearly always sat down at the patient's bedside on a stool when talking to them; this is subtle but something I don't usually see interns do.”
• It’s all about the team:
• Doing your part (and more): “Great teammate at the VA. Prepped d/c summaries and even [discharged] 8 patients in one day.”
• Entering orders: “Helped put in orders during work rounds, which helped with workflow and made things efficient for the team. Very willing to help out sister team and pitch in to get work done!”
• Lending a hand: “She is an incredible human. She is so perceptive as a teammate, recognizing when others need help, and extremely supportive going along with that.”
• Providing emotional support: “He is very passionate about checking in regarding wellbeing for all members of the team, particularly on emotionally challenging days and prioritized having debrief sessions including the medical students when our team encountered difficult diagnoses or sad outcomes.”
• Setting the tone:
• Calm under pressure: “I continue to be so impressed by her unparalleled kindness, intelligence, and leadership. Despite a large patient census at the VA, she skillfully triaged new admissions/consults and was never once flustered by the large volume of tasks and demands on her 28hr calls.”
• Spreading joy: “She came in every day with a smile and was so much fun to work with.”
• Spreading sunshine: “He was the resident on my sister team. He was always a bright ray of sunshine on the toughest of days. His positive attitude and general team-based approach to patients is refreshing.”
• Nicer than most: “The kindest possible human being, checked in with me regularly to make sure I was doing okay!”
• Commitment to learning climate: “It was clear from the beginning of the rotation that it was very important to him to invest in team dynamics and culture, to ensure everyone felt heard and comfortable, and that however difficult the workflow became that there would be shared purpose and mutual respect.”
• More on setting the tone: “He is an incredibly stabilizing presence on any medicine team. Specifically, he helps interns to feel in charge when leading patient care but also supported in challenging situations. He also is so incredibly invested in the wellbeing and success of everyone around him, all of which is compounded by his wonderfully charismatic and friendly personality.”
• Leading by Example
• Role modeling: “She is a model resident. She is knowledgeable and caring towards patients but also gives residents room to make mistakes and learn. She is kind, gentle and generous with her time and help. I have learned so much from her and hope to be like her as a resident.”
• Leading with kindness: “She was a great example of what a resident should be, she was kind, approachable, and had a calming aura about her that made the whole team feel comfortable.”
• Developing talent
• Balancing autonomy and supervision: “She is the prototype of a resident-leader. She allows appropriate autonomy combined with experience-specific oversight of interns and students.”
• Helping interns grow: “Made me feel very comfortable to ask questions, and gave me excellent preparation for being a senior next year. Was able to provide the perfect balance between autonomy and guidance that I needed as an intern.
• More on helping interns grow: “He was a fantastic senior who gave me both autonomy and support when needed. He let me handle an RRT but was in the background if needed, which was a great support for me.”
• Even more on helping interns grow: “I appreciated that she was willing to let me make a lot of my own clinical decisions and just check in as needed, since it is so late in the year. She let me practice doing care rounds which was a good experience for next year. She helped with discharge logistics when I needed it but otherwise let me pretend I was the resident for the day which helped me feel more confident about heading to PGY2.”
• Letting interns shine: “He is an outstanding team leader and generous senior resident. On rounds, he would consistently highlight the contributions of other members of the team. He supported his intern and student during their presentations, rarely interrupting and chiming in in order to help his trainee learn or develop a more sophisticated plan.”
• Even more on letting interns shine: “I also appreciated that she shared credit with me as the intern when speaking with the attending during rounds. ‘We were thinking’... etc.. She was not trying to steal the thunder with the attending, but rather allowed me to share in the successes.”
• Working with stars: “He was new to his PGY2 role on this rotation. He was given the tough task of managing two stellar interns. In other residents, I have seen this mean that a resident will step back and give interns autonomy. He was proactive in his management of interns, helped them understand logistics, fill knowledge gaps, and gave them the most optimistic and supportive atmosphere to learn in I have seen amongst any senior…He tailored his resident role to meet his interns needs.
• All-around excellence: “She is the consummate senior resident: brilliant, prepared, levelheaded, always available, kind, and supportive. I feel so fortunate to have worked with her in the MICU. She knew every last detail about all of our patients and was always a great resource when I needed help making a decision. She has experience with procedures and was able to supervise me even when our team did not have a fellow. She consistently came early and stayed late to ensure safe and effective handoffs for care of our patients. She kept rounds smooth and efficient even when it seemed like an impossible task. And she showed patients and their families compassion and patience - I learned a lot about conducting goals of care conversations from observing her. I hope other interns get to enjoy the warmth and confidence [she] instilled in a team.”

Having read these quotes, and hundreds more, I feel inspired and proud. You are a talented group of residents, but more importantly, you are committed to learning, to raising each other up, to spreading kindness, and to reminding us that at Yale, we find excellence everywhere we look.

And now, I’m off to hike up East Rock before I return to writing letters (or, rather, letting them write themselves),

Mark