A challenge: Pick a time during residency training where the burden of patient care and education coalesced with scarce family time or social life, and the urge to quit lingered on the back of the tongue. Think about someone you reached out to, whether it be a co-resident, attending, mentor, and think about their response. Was it positive? Or was it something along the lines of: “You’re lucky, I didn’t have anyone to call.” “ACGME is going soft.” “Residents now have it easy.” “I slept at the hospital for weeks straight.” “I did it; you can too.” “Shut up and keep your head down.”
In the age of rebuilding a new normal in light of the COVID-19 pandemic, health and wellness have been brought to the forefront of ACGME and residency programs across the county. However, a toxic, negative form of thinking lingers in the background, carried forward among the old boy’s club and handshakes behind closed doors perpetuating defensive medicine. To train new physicians on what it means to be holistic and to practice holistically, the teachings themselves must adapt and evolve and do away with the toxic mentality of negative idioms in place of teaching.
It is a problem within all residency programs. It is easily perpetuated as it takes the place of time, effort, and interest to stop, listen and help. Attendings must learn to recognize opportunities to teach from experience, rather than solely relying on the hierarchy in which you teach and oversee those below you. Learning stems from the attending as a person, as a physician, from their wisdom and years as a practicing physician. The art of medicine cannot be navigated solely from the pages of UpToDate or Harrison’s. With the attendings, residents, and interns in them, residency programs must break the cycle of exploiting idioms as excuses to teach. This cycle produces physicians where burnout is the highest, mental health issues are rising, and patient care is affected.
Journalist and author David McRaney discusses an interesting way to frame this problem. He discusses survivorship bias which is the tendency to focus on the survivors instead of whatever you would call a non-survivor in the situation. He states, “not only do you fail to recognize that what is missing might have important information, you also fail to recognize there is any missing information at all.” Survivorship bias in residency is looking up to seniors and doing what they did, listening to the advice they were given, following in their footsteps. Residency is then simplified and reduced down to whatever the person before you did. The opportunity for growth, inquisition, excitement, and self-driven learning outside of the pertinent matters is lost and thrown aside, as careless as “just get it done.”
I am not innocent in offering “just put your head down and get through it” as words of comfort when listening to a fellow co-intern reach out for guidance. It takes time to pause and work with the individual to problem-solve their technique, recognize patterns of behavior, and find points of inefficacy. Staying complacent with current forms of teaching models legacy thinking and hinders the evolution of residency programs. In identifying these problem areas, a better physician is molded and becomes more steadfast and confident in their abilities.
The solution to this problem is easier said than done. It starts with redefining the standards for residency programs, how progress is measured, and how we teach. Implementing a program that fosters equality over equity is key. Equality treats all students the same, but equity recognizes their different needs and gifts. The residency standards can continue to be raised and stay elevated; however, the path to get there can be individualized.
My goal is not to re-invent the wheel. However, there is an unspoken and unwritten rule that you must suffer to grow. I stand against that. As an intern immersed in hospital medicine in the midst of the COVID-19 pandemic, “suffering” is not how I want to look back at my residency. Having finished my intern year and starting my second year, I’ve grown in ways I can’t even describe. Most importantly, I’ve identified how I can continue to evolve and how programs can also evolve. I want to be pushed, challenged, and taught from the wisdom of those above me, not just thrown into the fire and asked why I burned as I claw my way out, melted to the bones. Let us transition from a primitive carriage wheel to an all-terrain, all-season tire and continue to evolve the residency programs accordingly.
Elena Keith is a family physician.
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