In this post, I explain the reasons why physician residency training can be a nightmare and why it doesn’t have to be this way.
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The nightmare
I had a nightmare the other day: I was back in residency training.
In fact, it was even worse. It wasn’t that I was transported back in time to when I had gone through my six years of residency training for urologic surgery. No – in my dream, I had for some reason been sent back to residency training as a full-fledged attending surgeon.
In my dream, I was initially hopeful. After all, I’d already been an attending urologist for almost a decade. Surely it wasn’t going to be the same hellish experience I went through so many years ago.
I was wrong. I was placed on call my first day on the job as a junior resident again. There was no orientation to the devilish EMR (electronic medical system) or the hospital-specific process of adding on surgical cases to the add-on board. The pager on my hip kept on blowing up with pages from the emergency room. There was a long list of inpatients, all requiring urgent attention.
To top it off, I had a despotic senior resident in charge, who just told me to “figure it out” and then quickly disappeared.
The last thing I remember was trying to dial the hospital operator for advice, but of course, I had the wrong number.
I woke up disoriented, then was filled with a profound sense of relief as I realized that it had all been a dream.
Real life would be better
Of course, things are different in nightmares. If this for some reason happened in real life, I’d be much better equipped.
For one, as a locum tenens, I’m used to quickly adapting to new hospital systems. I also have the benefit of almost a decade of experience as an attending physician. There’s very little I can’t handle anymore. Finally, there’s no way that I would take all the crap now that I took in residency training. I have a higher opinion of my self-worth than I did back then.
But that morning, as I blinked the sleep from my eyes and stared at the ceiling, I couldn’t help but reminisce. I thought back to all the reasons why my years in residency training were a waking nightmare.
Why my residency training was a nightmare
There were many reasons of course, but these were the biggest:
Power imbalance
Residency training is very hierarchical. The amount of authority given to residents based on their level of training is extreme. In my program, a second-year resident had almost absolute authority over interns and medical students. If my second-year resident told me to complete a task when I was an intern, I got it done, no matter what it took. Even though these residents had literally only 365 days more experience than I did, they held an extreme amount of power over my day-to-day existence.
As for the higher ups? It was even more extreme.
As an intern, if your second year is like your boss, the chief resident is the equivalent of the President of the USA. The attending physician? The attending is God and you’re lucky if they even know your name.
It’s crazier still that I believe much of this power imbalance is warranted.
The exponential knowledge curve
Much of the knowledge you get in medical school is not useful once you get to residency training. (Krebs cycle, anyone?). Therefore, intern year is almost like starting at a blank slate. There is an exponential amount of knowledge gained in that first year, which makes a second-year resident eminently more experienced than an intern. This experience can literally make the difference between life and death for patients in the hospital.
So it makes sense, to a point, for more experienced residents to have more authority than less experienced residents.
But when you take this power imbalance and mix it with the next element, you’ll start to see why residency training can be a nightmare.
Incompetent leadership
During my intern year, I rotated through different specialties of surgery. One of the most intense and taxing rotations was trauma surgery.
I trained in the county hospital in Los Angeles which was a level 1 trauma center. From gunshots and stabbing victims to motor vehicle accident victims, we saw it all. There was always an emergency to deal with and a ton of critical patients to round on. The shifts were technically 24 hours long, though it was always more like 26 by the time we got out of there the next day after morning trauma rounds.
It was also one of my favorite rotations of intern year. It’s not that I loved trauma surgery. I knew I was going to be a urologic surgeon, not a trauma surgeon. But our team had an amazing chief resident. He was all the things that you’d want in a leader.
Good leaders make all the difference
My trauma chief was competent, intelligent, technically skilled, empathic, humble, and led by example. He spread the workload equitably and made sure to teach as much as possible. There was no unnecessary hazing of his junior residents. He used his exponentially greater knowledge and skills to make our team more efficient. His great leadership made the trauma shifts enjoyable, despite the extreme demands and long hours.
But as I look back at that rotation, I realize now that I just got lucky — Sukgu was just naturally a good leader.
When I transitioned into the urology portion of my training, I quickly learned that many of the residents in my program were incompetent leaders. In my early years as a junior resident, there was far too much demeaning and far too little empathy. After all these years, I suppose I’ve forgiven them their incompetence, but I certainly have not forgotten.
After all, it wasn’t really their fault. There is generally no time devoted to teaching the values of leadership and team building in residency. Virtually all the training is devoted to learning medicine and surgery. This makes sense (to a point), as there is a huge amount to learn.
But if you want produce a resilient and happy doctor at the end of residency training, there are other topics that must be covered in residency, like leadership, the business of healthcare, and navigating the financial transition from residency to attending life.
Leadership, of course, is top down. It takes a committed and consistent approach that goes from the residency program director all the way down to the junior residents. Residents will model themselves after their attending physicians.
The stakes are quite high. Because without good leadership, residency training devolves into an artificial zero-sum game.
Artificial zero-sum game
There was a saying in my residency program: “We leave when the work gets done.”
This attitude is pretty common in residency programs, especially those that don’t have a shift-based approach. Like most surgical subspecialty programs, my residency program was small. We had only 3 residents per year, so there was no second shift to relieve you at the end of the day. You simply kept on working until all the surgeries were completed and all the patients were tucked in for the night.
While necessary, this approach to residency training was dangerous. It created what I think of as an “artificial zero-sum game.” It gave the sense that there was a fixed quantity of work, and for one resident to win, another has to lose.
Let me illustrate this concept. With this zero-sum framework, a chief resident could look at the list of consults and bedside procedures and think: “If my second year doesn’t do it, I’ll have to do it.” With this thinking, there is a natural inclination to put as much of the burden on the underlings as possible.
But this thinking is only half true. Remember – each additional year of residency training brings exponentially more knowledge and skills. What an intern can accomplish in four hours, a chief resident can accomplish in one or two.
Experience can shrink the workload
Thinking back, there were so many tasks I did as an intern and junior resident that were unnecessary or done inefficiently. I can still remember the first time I dictated a discharge summary for a liver transplant patient during my intern year. I sat down with a paper chart approximately the size an original Gutenberg bible and spent a half hour reciting the entire patient’s clinical course into the phone.
Later, I saw an attending transplant surgeon recite a similar discharge summary in about three minutes. It wasn’t that she spoke at hyper-speed. She just knew that all the details during a patient’s hospitalization don’t need to be recorded in the discharge summary. Her experience allowed her to complete the same task ten times faster than me!
I saw this type of phenomenon time and time again during residency. With a quick piece of advice or demonstration, good senior residents and attendings could drastically improve the efficiency of their team and shrink the workload. They just had to have the empathy and compassion to do it.
Residency, like wealth, is not a zero-sum game.
Malignancy is cancer
The word “malignant” is used to describe residency programs that are toxic, unsupportive, and abusive. It’s not a mistake that this word is also synonymous with cancer. Because just like a cancer, a malignant residency program can eat away at the life of a doctor in training. It can make a young doctor doubt their self-worth, their career choice, or even consider suicide. In this new reality of a national doctor shortage, we can’t afford to have any malignant residency programs.
Conclusion
The good news is that residency training doesn’t have to be a nightmare. All you need is competent leadership that can navigate the inherent power imbalance of physician training. From the second year resident to the attending, there must also be a realization that residency is not a zero-sum game. With just a bit of empathy and compassion, more experienced physicians can make an incredible impact on the lives of their juniors.
Many well-trained doctors graduate every year without having a nightmarish experience in residency training. Let’s make this the rule, rather than the exception.
As my own experience in residency taught me, it’s not the quantity of work or quality of surgery that defines a residency program. In the end, it’s the people.
Daniel Shin, MD
The Darwinian Doctor
PS – despite the sentiment of this article, I came away well trained from residency. A little bitter and disillusioned, but well trained. I hear it’s much better now.
How was your experience in residency training? Let me know in the comments below!
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