Do you know how big you are?

Wednesday's precourse “Battling Burnout Together: You Are Not Alone” included an explanation of psychological size, which includes both innate attributes (e.g., stature, age, race, ethnicity) and acquired attributes (name, title, reputation).


While psychological size may be a new term to some physicians, many can remember how “big” they felt as trainees versus how they feel as attendings. During Wednesday's precourse “Battling Burnout Together: You Are Not Alone,” Justin Roesch, MD, FACP, explained that psychological size includes both innate attributes (e.g., stature, age, race, ethnicity) and acquired attributes (name, title, reputation).

A story from his own training highlighted its effects in medicine. Dr. Roesch, assistant professor and assistant director of the assessment and learning program at the University of New Mexico School of Medicine in Albuquerque, recalled the first day of clerkship during his third year of medical school at a new hospital in the obstetrics and gynecology department.

“I got there, and I was immediately thrust into the [operating room],” said Dr. Roesch. “I didn't know the patients, I didn't know the attending, I didn't know anyone from nursing or staff who were in there, and they were in the middle of a C-section.”

So he stood by quietly, trying to observe the anatomy. “I was trying not to say anything or make too much noise, just stand there quietly like a good third-year medical student should,” Dr. Roesch said.

Then, as the attending was finishing the procedure, “I was fairly confident they had left the lap pad behind,” he said. After wavering on what to do next (the patient had an epidural and could hear what was happening), Dr. Roesch decided to speak up. “I tried to whisper to the attending, ‘I think you might have left a lap pad back behind, in the patient,’” he said. “And I remember, the attending just looked up slowly, stared at me, and said, ‘Who are you?’”

The scrub nurse maintained that the counts were right, so the attending looked back at Dr. Roesch and said, “If I open her back up, and you're wrong, I'm going to call your dean and have you expelled from medical school.” The attending then began to slowly open every suture, looking up at Dr. Roesch in between each cut.

After the last suture and behind the uterus, there it was: the lap pad. “In that moment, I was just relieved. ... And I was hopeful that perhaps afterwards, there'd be some affirmation,” he said. However, there was not a word from the scrub nurse or attending.

“I tell this story not as a self-serving story of heroism, but to emphasize what would have happened if I would've been wrong,” Dr. Roesch said. “Because if I would've been wrong in that moment, I probably would have been petrified about speaking out ever again, and you can think about the clinical harm that could come to patients thereafter.”

The story highlights the significance in academic medicine of both psychological size and safety, which Dr. Roesch defined as “the freedom to be fallible, but with the support to succeed.”

When a hospital's culture lacks psychological safety, learners can experience fear of judgment, humiliation, or reprisal, lose confidence, and eventually withdraw from social or academic situations, he noted. The end consequences are more dire: burnout, depression, and suicide. “This can also lead to worse clinical outcomes,” Dr. Roesch noted.

To avoid these consequences, he offered three key ways that attendings can create psychological safety in their relationships with learners.

1. Set the stage by establishing realistic expectations. Medicine is high-consequence and mistake-prone at times, and it's important for physicians to recognize that they thrive in that setting through collaboration, said Dr. Roesch. “It's important for us to understand that we are capable of making mistakes, no matter where we're at in practice ... and to elicit feedback from those around us,” he said.

Dr. Roesch encouraged attendings to own their fallibility and establish to learners that feedback is an expectation (plus, “good job” is not feedback; it's praise). “I want our team to understand that the faster we fail, the sooner we'll succeed,” he said, adding that it is also important to create an environment of shared responsibility. In addition, make it known that anyone can call a timeout at any time. “The timeout is extremely powerful ... It's almost like the safe word for the team to use sometimes,” said Dr. Roesch.

2. Increase the psychological size of others. Remember the power of names, he advised. Frequently use the preferred names, pronouns, and formal titles of learners, and give them ownership of patients. “I try to make sure that I identify my student, first and foremost when we walk into the room, as the first person who is in charge of the patient's care. I let them know that I'm the backup, and I'm there,” Dr. Roesch said. “Students love that, and I love empowering them in that way.” Meaningful rapport can also be encouraged by listening to trainees with conviction, he said.

3. Decrease your psychological size. If you're comfortable with it, inviting trainees and others to use your first name in less formal settings can be powerful, he said. “Just the invitation suddenly humanizes you. It takes away sometimes this high level of awe, the superpowers that the medical students and staff might see behind you, and you're a person,” said Dr. Roesch.

One final tip is to indulge in self-deprecation. As a third-year medical student, Dr. Roesch thought ahead and wrote down memorable stories and lessons learned during training. “When I'm working with a student, and we're getting ready to do a paracentesis and that needle is shaking a little bit, I can just drop this cool story on them,” he said. “Like, ‘You're not even going to think about this paracentesis when I tell you about the time that I flubbed my first paracentesis.’”