When a Student Extern Disrupts an Office’s Established Procedures, How Can an Owner/OD Regain Control?

DR. ABERDEEN’S practice was set in the outskirts of Dover, Delaware. The majority of patients had vision care plans and wore contact lenses, and several months ago she’d written to her alma mater offering to become a preceptor. The externship director listed Dr. Aberdeen’s office as a contact lens rotation, and soon a list was sent with student names and dates.

The first extern, Emily, was happy to be accepted as this meant she could commute from her grandparents’ home 30 minutes south of the office. Dr. Aberdeen spent a great deal of time preparing for her extern, including establishing a work station, a series of enrichment assignments, and a customized office policy manual. Dr. Aberdeen also held a 10-minute huddle with her staff to explain the unique role of an extern within the office. While Dr. Aberdeen didn’t directly manage or supervise the staff, she would be overseeing all externs personally.

Emily’s first day was spent shadowing Dr. Aberdeen in patient care. As this was Emily’s first externship, she was excited and projected confidence and charisma. Dr. Aberdeen was flummoxed. She had expected Emily to remain silent while shadowing her, speaking only if asked a question. Instead, her extern was engaging family members in idle chit-chat during the exams, or offering unsolicited treatment plans.

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The last patient of the day was a very nice man Dr. Aberdeen had seen for at least 10 years. During the slit lamp exam, she invited Emily to quickly look into the ‘scope over her shoulder, where the beginnings of a nuclear sclerotic cataract were in focus.

“Cataract,” Emily confidently announced to the room, as though she were on a quiz show. The patient sat back quickly.

“I have a cataract?!” he exclaimed, looking frightened. Dr. Aberdeen did her best to back-peddle and educate the patient about his pre-cataract, a conversation she hadn’t planned to have for another six months.

Despite regular coaching, her extern continued to put her educational exuberance ahead of Dr. Aberdeen’s relationships with her patients. Monovision patients were advised that they were wearing ‘old technology’ and should consider multifocal lenses; those with prescribed prism were given lectures on the virtues of vision therapy; and dry eye patients were encouraged to ask for punctal plugs, a procedure Dr. Aberdeen didn’t feel confident performing.

A breaking point came when Dr. Aberdeen learned Emily had been criticizing some of her policies to the technicians. “These vision care plans are supposed to include dilation and the full contact lens fitting,” she said with authority. “It’s not right to charge for follow up visits, you can get in trouble for that.” One of the techs brought the information to the office manager, who circled around to Dr. Aberdeen. She felt offended, and in an attempt to mitigate some of her stress she found herself assigning Emily to more workups and fewer complete exams. This prompted more complaining, including comments about ‘free labor.’

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Just before Emily’s midterm grades were due, Dr. Aberdeen sent an email to the director of the externship program. “I can appreciate how engaged Emily is in patient care and the profession,” she wrote, “but this is my business. I don’t think she’s fully appreciated that. Her clinical skills are sound, but I had expected to spend more time teaching and less time cajoling.”

Expanded Real Deal Responses

Gary S. Muskegon, MI

If I had a patient with a 10-year history of pre-cataracts, I would have told him nine years ago, confirming each year that they are still way off in the future and not to worry. Lots of monovision patients? This is a wakeup call! Don’t be a dinosaur. If you know what the managed care rules are, then educate the intern who only has ivory tower learning. If you are violating the plan rules, either drop the plan or change before the plan calls you on the carpet. The intern must be addressed by the doctor as to what is expected and to not jump in or override the doctor’s decisions. If the Don Quixote-like jousting with the way the practice is run doesn’t stop, the intern will damage her future prospects of being employed anywhere.

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Robert M. Edina MN

The first mistake Dr. A made with Emily was assuming she would act in a certain manner without setting expectations. To improve the balance of her time there, Dr. A should tell Emily exactly what she expects and what behavior is unacceptable i.e. gossiping with the staff, etc. This insight will help Emily in her career. As the program director, I would have a conversation with Emily about the importance of listening to Dr. A and discussing patient issues in private and not in front of staff. I would also let her know the externship is a privilege and should not be taken for granted. There is not a line between business owner and teacher. There is much to learn from both. She should take full advantage of a great opportunity.

David G. Beckley, WV

She should have told the extern to shut up and not engage in any direct communications with the patients about diagnosis and treatment or any criticism of the doctor’s office policies. The extern was there to learn, not manage. When the extern enters the real world things don’t always happen like in the school clinic. Very rude.

Chani M. Highland Park, NJ

I wouldn’t have waited so long to sit down with Emily and tell her exactly what was expected of her. I would have nipped this in the bud on day one in a more aggressive manner. If I was the program director, I would call Emily in and tell her that her grade was in trouble unless she shapes up. As a preceptor and business owner, expectations, as well as written guidelines, should be discussed and dispersed. In order to salvage the rest of the rotation, I would sit down with Emily and have a really candid discussion about how to turn it around and make sure the staff knows that it is being dealt with so that simmering resentment does not ensue.