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Medical Student Perspectives: Disarming Gunners

During medical school at the University of Vermont College of Medicine, encountering “gunners” was so infrequent that for the most part, the term, “gunner” was used by my classmates almost affectionately for a friend who studies too hard for the boards or crams a lot for a rotation. However, a couple of students, during third year, were rumored to be the real gunners. Gunners are medical students, or students in any professional school (e.g., law, veterinary, business, etc.), who will mow down anyone they perceive to be a threat. They are motivated to get a good evaluation, a good grade and thus a secure lucrative future in their competitive field of choice.

I had an irritating experience with a gunner. I was in a seminar about management of chronic kidney disease and acute kidney injury, given by one of our favorite renal attendings. I was unclear about how to handle volume resuscitation in a septic patient with kidney disease. So I asked the attending my question. However, instead of hearing his explanation, I was appalled by my classmate haughtily explaining what he would do in such a situation. He looked at me like I wasn’t supposed to ask a question. I patiently waited for the attending’s response. I was furious that this guy made me look stupid in front of a group of students and residents. After the attending left the room, I turned to him and let him know I would not permit him to embarrass me publicly ever again, and he apologized.

Being direct and assertive worked in this case. I think it worked because he didn’t even realize he was being a gunner. I think he was keyed into the lecture and was trying to get approval by showing off at my expense. He was desperately trying to get into a special subset of one of the most competitive fields of medicine and he was stressed out, insecure, and having trouble managing his anxiety about an uncertain future. After match day, when he was successfully placed in a program of his choosing, he reverted back to the chap I knew as a first year, amusing, and fun to be around.

Why do nice, sociable, fun folks become gunners? Neil Hyman, M.D., a sage, savvy Professor of Surgery at UVM COM, compared med students’ process of learning to navigate the wards to small children trying to master new tasks. “It’s like the way my kids are…one of them sits by the pool and slowly gets in and the other jumps in and splashes around to get my attention. On the wards, some of you will be splashers and some of you will get in at your own pace. Don’t hate the splashers. That’s just who they are. And frankly, most residents and attendings can see right through it.” I have always tried to keep this in mind: some of us need lots of approval and reassurance when we try new things because we’re nervous. Unfortunately, insecurity may cause gunners to seek approval at other students’ expense.

Outwardly, such students may look like better clerks because they recite every detail from their Step 1 Boards preparation, whether asked a related question or not. However, these students lose sight of the goals of the team and the importance of teamwork according to Joseph Wright, MD, a Beth Israel Deaconess internal medicine resident and writer, who gave an insightful NPR commentary on “gunners” when he was a med student.

Fourth year medical students generally do a couple of sub-internships (aka, acting internship at UVM COM). In these rotations, fourth year med students work with their resident and work on the team as though they are a first-year resident. I did mine in medicine and one time, I saw a more overt type of gunner behavior. A competitive third-year student on my team made her colleague’s time on the rotation rough, by putting him on the spot when he couldn’t answer questions. When he was asked a question by the attending on rounds, she would interrupt his thinking to interject answers. This student’s confidence was shaken during these episodes and it was difficult to watch. I can only imagine how difficult learning was under those circumstances. During this time, I told myself that when I was an intern, charged with teaching and mentoring third year medical students, I would try to help change such uncomfortable, unproductive team dynamics.

One of my mentors, Lewis First, MD, Professor and Chair of our Department of Pediatrics and for the past six years, also our Senior Associate Dean of Medical Education who is stepping down this year to become editor-in-chief of the journal Pediatrics, believes that competitive behaviors among med students can and should be changed. It is important “to refocus them [such students] on their patients rather than their peers and teachers, and have them advocate on behalf of those patients collaboratively as team players rather than focus their priorities on their personal grades or scores in an exam or rotation.”

Although refocusing gunner-type behavior is ideal, what do you do when residents and attendings overlook or actually praise the student who makes learning difficult for others? In those cases, I would ask the clerkship director or another advisor who is neutral for help. I would not focus not on the gunner’s behavior, but rather, the effect it has on your learning. Ideally, the clerkship director can discuss the situation and help mediate in the situation to help colleagues construct a better working relationship.

Ultimately, we all have career goals. The methodology to securing honors can be elusive, but in the end, learning to become the best physician you can be is most important. In trying to impress and “beat the system,” gunners often lose sight of the true goal of training, and ultimately, risk cheating themselves, their teams, and their patients. I hope you never encounter gunners on the wards. But if you do, remember to be assertive, practice empathy, and focus your priorities on taking care of your patients as a member of the care team so the gunner will do the same. And if things are still tough, ask for help.

Emily Glick, MD
PGY-1, Fletcher Allen Healthcare
Former New England Representative, ACP Council of Student Members

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Back to July 2009 Issue of IMpact

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