Imagine being at a conference where 1 in 3 attendees are depressed and 1 in 5 wish they were somewhere else … fun conference?
I was reflecting on my residency when I wished that an attending would have stuck up for me just once when I was getting abused – three particular nurses, two residents and one physician stand out. I made a promise never to let that happen in front of me. A couple of years ago, I kept that promise when I intervened when a nurse thought fit to dress-down a resident publicly in the ER.
What? I’m being soft? Sure some people require a verbal reality check when they are out of line, but there seems to be a culture of “resident aware” and “resident needs to suck it up” that frankly is uncalled for and its time it went away.
These young doctors are the backbone of the entire system. They come in all sizes and increasingly they are not putting their lives on hold for medicine – which means added stress from juggling young families and a career that expects so much. They should be valued and nurtured – like Olympic athletes.
It's a long road
I know what you’re thinking … You’re thinking that “in my day we knew how to work hard” “we just sucked it up” “I never called in sick” “I never whined or needed a personal day“. Okay – give yourself a pat on the back for being macho. When you were flying around the hospital all sleep-deprived. How productive were you? How many errors did you make? How compassionate were you? Do you not think medicine is more complex nowadays? Do you not think that you’ve become a teeny bit cynical?
Medicine becomes more complex on a daily basis. Patients demand safe, conscientious and evidence-based care. You think that residents can provide this when they’re stressed out, depressed running around the hospital wishing that they were someplace else? Seriously??
From this 2006 Alberta Study When 1 in 5 residents wish that they were doing something else – that’s NOT right. We all came into this profession to make a difference. Somewhere along the line we become depersonalised and jaded. Guess what? This reflects in your work [2002 US Study]. So when we’re being unfeasibly tough on them – patient care suffers.
That’s right … poor resident wellness = poor patient care
Perhaps we need to stop thinking of resident wellness as being “soft on residents” and start recognising that it’s actually a health issue. We all need to be part of the solution. Here are ways to Combat Residency Stress.
Start by having a Program for Wellness – this should be Institution-specific and NOT program specific. It should come with a Sh-load of resources. Confidentiality is paramount.
Get with the program – You’re not being soft on them. You’re nurturing a future star in your specialty – SUPPORT THEM. (You want them to be mediocre then maintain the status quo).
Learn how to diagnose stress and burnout – Should be easy … you were a resident [and human being] once. If a resident is under-performing, burnout is probably higher on the Ddx than incompetence – ask some questions!
Have an annual retreat– Retreats are a good way to blow off steam, rejuvenate and reflect.
Have an ombudsman-person– they need a shoulder that is at arms length from the program.
Check in with them regularly – Focus on their mental well-being, financial well being and family life. Set goals.
Play together – Creating a sense of community is vital to stave off the isolation that many residents feel.
LipheLongLurnERdok 
I am going to add a few thoughts, while agreeing that the years of intimidation and overwork are gone. this is a good thing. however, not all changes, in my view, have facilitated the development of strong residents. here are a few of my ponderings, for what it’s worth.
I am extremely thankful for ALL of the experiences that I obtained during my residency – experiences that I got to have because my experience was not diluted with other trainees, NP’s or a union contract that is developed to the degree that it is.
For example:
a) I am so thankful that I got to be ‘the doc’ on neonatal transports that included playing ‘north of 60’ in uranium city, flying into la ronge over the lake in the fall, and many other flying and road adventures that helped me to develop neonatal resus skills in a variety of circumstances
b) I am so thankful that i did not have to ‘share’ my PIcu and NICU rotations with other trainees, such that I could embrace the fullness of the clinical experiences, which included, because of volume, the ability to make decisions and triage the work.
c) I am so thankful that the mantra and culture during my training (1994-98) was learning to be compentant, not ‘comfortable’
d) I am so thankful that most of my learning came from patients and not from e-learning. There is abolutely nothing that has taught me about the nuances and ‘fife’ of clinical medicine like seeing patients – as many patients as I could….. and can.
I am all for the changes…. but i would argue that the overall training needs re competancy has not changed. Are we willing to extend their residency by a year to get the PATIENT encounters in? A combination of stricter union rules and double the number of trainees in the program I am most involved with, has resulted in trainees who put post- call rules before learning opportunites from staff led teaching/rounds, a premature (in my view) delegatin of senior teaching junior (or perhaps ‘delegating’ to junior), when every single year in this particular residency has has limited opportunity to triage, manage and make decisions when there is a bit of a pressure cooker.
I am terribly thankful that I got to walk uphill (both ways) in my dad’s pyjamas…. could improvements have been made at that time? absolutely. Am i thankful that the culture of learning, in most ways have changed? for surely!!! but, the needs of the PATIENT and what the PATIENT needs clinically, has not changed and it is to THIS end, that win-win should be sought for – maximizing the learning of the trainee without in any way compromising the needs of the patient in real time, nor the ability to manage patients in the career ahead.
vicki
p.s. the peds residency program has a mentorship – where attendings are assigned a resident for the possibilties of getting together to discuss how things are going, listening, mentoring, etc. seems to be a good thing.
Agree with the detriment of diluted learning but there are advantages for having other learners around [fair distribution of work load and peer learning].
i’ll not disagree about the value of patient encounters, but patients can’t teach you about physiology, evidence based medicine and how to be a medical expert – so you need both p-learning and e-learning 🙂
Your reflections on trainees putting rules first I think are a generalisation – [e.g. one of my residents going home from academic half day saw the attending specialist going down to the ER to help with consults – so he volunteered to go help].
I think it swings both ways. Learners that are valued and happy will, I think go above and beyond. Those that are not will say WIIFM? [perhaps some of this begins with the admissions and selection process] I also think that we can lead by example – and create a culture that is a balance of service and learning.
I think that we will see a competency-based training in our lifetime – i think that there’s no way around it. [As you correctly allude, virtual learning can only do so much] and truly all adult learners are different in their learning curves.
I agree with patient service 100% … which is why I think that resident wellness = patient wellness. And I think that post call rules came about first and foremost for patient safety and the recognition that people that are physiologically impaired shouldn’t be doing patient care. I would argue that you’re not in any state to learn anything after being up all night either.
In the end our experiences do mould us and I for one think that I also got a good experience from working hard during my residency. But I would rather have a happy, thriving resident as my ambassador than the ones that you [and the literature] illustrate.
thanks
Thanks Nadim….
did not mean to imply generalizations.
Also fully agree that being tired is not the goal. However, since the overall competencies remain and patient needs remain, might it well be that some of the training programs should be longer in order to obtain those competencies, as I suggested. In no way did I mean to suggest that the goal is to have tired and unsafe residents (hence the thrust behind tighter union guidelines). However, not all nights are horrible and at times it would be fine to take advantage of the learning the next day. this will always be about internal drive/character/motivation of individuals, i think.
Given the enhanced union contracts and worlkoad, what is still lacking in your view regarding workload and experiences? I think that the peds program does quite a good job of learning opportunities , yearly retreats, parties etc.
My best learning re physiology etc came from reading around patients and then honing it the ‘book’ stuff combined with the clinical presentation. Individuals have different styles of learning, I think. This is the style the worked best for me. However, this is in no way to downplay virutal leaning, only that in my view, my best learning came from patient encounters and reading around them. Dividing workload is great if there is truly an overabundance, but some degree of work is required in order to learn management competencies. In the Peds program, if this capacity is exceeded, it is the job of the attending to come in to help. In the case of Peds ER, the trainee is never the ultimate manager, the staff is. So, is some ways, I see Peds ER /ER as the perfect learning environment (hence it’s popularity) – immediate feedback, vingette type learning, breaks whenever needed and ability to manage with a safety net of the attending. This rotation is one of the strongest in the Peds residency training program, which we can all be very proud of!
Finally re why we are happy , or not….. complex question and multifactorial I would say.
Good discussion and food for thought N!
Vick
Vicki – thanks for the discussion and clarification.
“Motivation” is a whole other topic [coming soon]:).
Knowing [and effectively measuring] that we’re doing a good job of teaching [i.e. knowledge transfer] is the holy grail of educational experts. [another blog topic? ]:)
I agree 100% about patient encounters + reading around cases as this is also how I learn best. And on the experience that we provide. I think that we do provide a great learning experience.
We live in a world of contracts – they are a double-edged sword. Previous to them … residents worked 1:2 call and 40 hour shifts. They would also get killed in contract negotiations with the health region.
As you correctly allude – it seems individual how some people may chose to be sticklers or not. … I agree that ultimately residents have to assume responsibilty for their path as well.
My original post was a reflection on how we can help residents to thrive.
keep th discussion flowing
long discussion run N! new record for your blog! did I get off topic. : ) yes, helping residents to thrive IS important. I do wonder if the Peds ER/ER rotations are inherently able to help with that because of the nature of how the rotation is run. I suspect it to be true and wonder if there are things done in this rotation that could be emulated in other rotations.
the contract IS important – don’t get me wrong! I also have a vivid experience of clear harassment and intimidation – that actually wound me up in the then Dean’s office along with the head of surgery and my dept head , to defend myself against situations occurring when we had a peds cardiac surgery program….it is something that would have not been tolerated even 18 years later. It was an environment where ‘thriving’ was impossible.
the contract IS important and necessary.
i suspect that what I can do personally simply resides in my day to day interactions, including ensuring that they are free to attend all lectues and 1/2 day stuff. I think also setting goals can help them to thrive… hence I think our 10 artiles will be a good thing re thriving.