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January 16th, 2020

Reflections of an Aspiring Clinician-Educator

Frances Ue, MD

Dr. Ue is a Chief Resident in Internal Medicine at Cambridge Health Alliance in MA.

Recently, I had the pleasure of hiking up Roys Peak in South Island, New Zealand. A challenging 1586-meter summit that offered magnificent views of Lake Wanaka and snow-capped mountains of the Southern Alps. On this hike, devoid of phone calls and pages, I reflected on my journey as an aspiring clinician-educator. Many of us (like my fellow blogger Prarthna in Why Did I Spend an Extra Year as a Chief Resident?) want to teach, become better at this skill, and have a career that supports this goal.

So, how do we create careers as clinician-educators (with a big E)?

Feeling exhilarated to be at the peak! Roys Peak in South Island, New Zealand

In medicine, the clinician-educator term refers to, “a physician whose primary role is caring for patients and who has formally incorporated educational principles and scholarship into her/ his job description.” These physicians distinguish themselves from other clinicians by, “using evidence-based educational constructs to teach around patient illness and wellness, and converting those constructions and innovations into scholarship.” (Acad Med 2018; 98: 1764)

Harvard Macy Institute’s program for postgraduate trainees is one way to gain theoretical and practical skills towards a clinician-educator career. I had the privilege of attending last month. This three-day intensive program is paired with a year-long scholarly project in medical education and serves as an entry into the Harvard Macy community. I walked away from the course feeling excited and inspired. I’d like to share some highlights of what I learned from the course and about myself.

What I learned from the course

Kirkpatrick’s Outcomes Hierarchy

  • How to turn innovative ideas into scholarship

Beckman and Cook (Med Teach 2007; 29:210) is a must-read for anyone interested in medical education! These authors describe a three-step approach to designing scholarly education projects grounded in the theoretical basis of Boyer and Glassick: 1. Refine the study question, 2. Identify design and methods, and 3. Outcomes. In particular, Kirkpatrick’s outcomes hierarchy has been invaluable in developing targeted outcomes.

  • Practical tips for advancing my scholarly project

I am forever grateful to my project group with mentors Alan Leichtner and Arielle Langer, and members Yakira, Christina, and Larissa. Not only were we a powerhouse team of #WomeninMedicine (and Alan), but we shared thoughtful feedback on each of our projects and practical tips for success. Arielle would often emphasize celebrating the small wins; an embrace of the small advances of our work.

  • Ways to seek training in medical education

In addition to training at the Harvard Macy Institute, we discussed ways to seek out educator development opportunities at our own institutions (for example, a medical education residency track). Coursework is also available at the Preceptor Education Program for Health Professionals and Students. And lastly, fellowship training in medical education also exists at Stanford and Rabkin/Beth Israel Deaconess Medical Center.

What I learned about myself

2019 David A. Kolb, Experience Based Learning Systems, Inc.

  • How I learn and teach

I learned that I have an accommodating learning style (a combination of concrete experience and active experimentation; Kolb learning style inventory) and an apprenticeship perspective on teaching (Teaching Perspectives Inventory).

  • The joy of micro-teaching

I taught a micro-teaching session on ‘how to run a marathon’ with my group members pretending to be runners. It was an energizing exercise that included the teaching segment being recorded and then viewed by me for self-reflection and by the group for feedback. I learned that my bubbly energy becomes much more magnified with enthusiastic learners.

In addition to the highlights noted above, I think what makes the Harvard Macy Institute so special are the people; the community of scholars and faculty who share boundless passion for medical education. Sometimes the journey toward becoming a clinician-educator can feel like scaling a 1586-meter summit. But with the guidance and mentorship of my Harvard Macy community, I know we will all reach the peak together.

I would love to hear from trainees and faculty passionate about medical education! Feel free to post a comment below or tweet at me UeFrances.

 

NEJM Resident 360

December 19th, 2019

Yogurt – The Cure to Resident Burnout

Dr. Daniel Orlovich

Dr. Orlovich is a Chief Resident of Wellness at Stanford University

What is the latest answer to resident burnout? It may surprise you. 

Recent research from a large Midwest academic center suggests that not one but two dollops of yogurt may help stymie resident burnout. “When we first started to look at the reasons why so many residents were burned out, we couldn’t understand it,” stated the associate program director, “so we started a dig a little bit.” This digging, of course, did not involve actually asking those most affected by resident burnout — residents themselves. 

So, to address that gap, here are some thoughts from actual residents: 

  • One intern referenced the financial strain felt by some. “I mean, average debt has gone up 270% from 1986 to 2018.” (Acad Med 2011; 86:840 and AAMC.org student debt)
  • Another brought up the pace of the current healthcare system. “In 1972, the average length of stay was about 14 days — in 2009, it was 4.8 days (JAMA 1990; 264:1984). And residents in 1972 and in 2009 took care of the same amount of patients, too” (J Health Soc Behav 2012; 53:344).
  • Another senior, while clicking on the computer, stated plainly, “the average ER physician clicks more than 4000 times per day and spends 44% of his or her day doing data entry (Am J Emerg Med 2013; 31:1591). And another study showed that IM residents spend as much as five times the amount of time documenting care as providing direct patient care” (Ann Intern Med 2017; 166:579).
  • A current PGY3 thinks the solution is probably more nuanced: “Where is the right balance between educational versus service requirements? How about the right amount of supervision versus autonomy? These aren’t such a black and white issues, I suppose. I’m not saying residency is harder than it used to be — it is just different, that’s all.”

None of these facts were considered for the study. 

“Residents now have the 80-hour cap. That means they work less than residents did before. So, there shouldn’t be any burnout. Burnout is all about hours worked,” stated the associate program director, noting how all professionals work hard early in training. 

Yet, compared with other college graduates, residents are 1.6x more likely to be burned out, and 2x more likely to feel depersonalized, and they score lower on mental, physical, and emotional markers for quality of life (Acad Med 2014; 89:443).

Without seeking to understand or pinpoint the root cause of the burnout, and after residents fell asleep during the lecture on sleep hygiene, a one-size-fits-all approach was proposed — yogurt. 

How do we solve resident burnout? With yogurt, of course.

The program started to incorporate a mandatory dollop of yogurt during wellness lectures. This allowed the program to check off the box for “wellness” activities. Serendipity, the bedrock of all discoveries, occurred: as a medical student entered into this wellness lecture hoping to eat the free food, he ended up receiving not one but two dollops of yogurt. 

“And when I saw the medical student’s face when he received two dollops of yogurt, I knew we were on to something,” said the associate program director. “Without any resident input at all, we then started a ‘two-dollop’ lecture. This was followed by a mandatory yogurt training module. Then, we worked with IT to create a checkbox to be clicked in the EMR to show that training was complete.”

Since those changes have been made, the following lectures were Band-Aids. Not in the figurative sense — actual Band-Aids were given out. Of course.

 

Author’s note:

This is satire. Of course, residency has become more humane.  To have the opportunity to serve as a physician is an incredible privilege and special honor. Of course, it takes many hours to learn how to be an excellent physician. However, it doesn’t have to be any harder

The question isn’t whether wellness lectures work. The issue is how they are done. Presenters sometimes miss the mark when they hand down mandated solutions, refuse to seek resident input, and fail to show an interest in understanding and acknowledging the current training environment. When done right, though, they can confer admirable and positive results. That means seeking out resident-led initiatives, being flexible in when they are performed, and addressing concerns that speak to residents. 

 

NEJM Resident 360

December 12th, 2019

Why Did I Spend an Extra Year as a Chief Resident?

Dr. Prarthna Bhardwaj

Dr. Bhardwaj is an Internal Medicine Chief Resident at UMMS – Baystate Medical Center in Springfield, MA

I was in conversation with a residency applicant recently when we broached the topic of my career plans. I explained that I was interested in pursuing a hematology/oncology fellowship in the future. He asked “Why did you do a chief year, then? Were you trying to improve your application?” At first, I was somewhat offended, but I quickly recollected the number of times I have been asked why I chose to do a chief year. For folks who are genuinely interested in pursuing a chief year, here is why I chose to do it:

To hone my teaching skills

If you are interested in an academic career and want to teach students, residents, and fellows, you must know how to do so. So, this one is obvious.

I started teaching medical students early in my residency. This experience made me quickly realize that I had to read a lot to lead these sessions, because these med students often asked ridiculously hard questions about seemingly obvious things, and I did not have an answer. Sometimes, just knowing a lot about a topic was not enough — I had to know how to deliver that content to keep my learners engaged. I am still looking for a better way to learn medicine!

Chief residents typically lead, facilitate, or present didactic sessions daily to large groups of learners at different levels. This includes morning reports, noon conferences, academic half days, and simulation sessions. Most residency programs have medical education–related sessions, workshops, and information for chief residents that equip us with tools to be better medical educators.

A welcome change of pace

After working rigorously for the last 3 years during residency, I thought that a chief year would help me “take it easy” before I transitioned into an emotionally draining fellowship. What that really meant was having weekends off and a more consistent schedule which would allow me to pursue things I love, but missed doing during residency (like reading a book or binge watching a series on Netflix). However, a word of caution: Chief residents must be prepared to be on call 24/7!

I knew I wanted to pursue a fellowship even before I started residency. However, for a lot of people who choose to do a chief year, the extra year allows them to figure out truly what they want to do. They can transition into subspecialty training, academic hospitalist jobs, and primary care positions in different healthcare settings.

A great way to give back!

I was a wallflower during medical school. Coming to my program for residency helped me come out of my shell (or so I think). Moving from a different country, 8000 miles away, I was wholeheartedly embraced into the program. The incredible opportunities that I got at every point filled me with increasing confidence in myself and my abilities. That is what working in a supportive environment can do for an individual.  In addition, I was also encouraged during residency to actively involve myself in other medical organizations, like the Massachusetts Medical Society and the American College of Physicians, which opened a lot of wonderful networking avenues for me. I am grateful for the support I have received personally and professionally. This made me want to contribute in my own way to the legacy of the program. I anticipated that this role would involve passionately advocating for residents, and bringing meaningful change and innovation to the program where necessary.

House staff photo

House Staff Photo on the Hill May 2019. Photo taken by Todd Lajoie

My family

Given the unpredictability of a fellowship match, especially with visa restrictions, doing a chief year was the most definite way for me to stay under the same roof with my husband. He started his fellowship at the same hospital during the 3rd year of my residency and had 2 more years after that to finish. Let’s face it – what we do in medicine is incredibly hard at times and having the support of family is truly a blessing!

 

Personal and professional growth

Saving the best one for the last! I applied a chief resident year, because as I viewed it as a great year for personal growth for me. Being more empowered by learning how to navigate difficult conversations, how to manage different kinds of people, how to negotiate, and how to break bad news was important to me. This is exactly what I would do in the future as a hematology/oncology doctor and, hence, I needed these skills! I have been at this job for 6 months, and my growth curve looks like this: In the past 6 months, I found myself in situations where I dealt with conflict head on because no one else could do it. For example, it was incredibly hard to tell a resident that they would not get vacation time during their time on the floors. It is well known that these are not typical vacation weeks, but have you ever been the person saying “No” to someone?

The most important aspect of my growth is in the way I give and receive feedback. As a resident, constructive criticism always made me feel uncomfortable, even though I tried to have an open mind. This year, I truly learned that ‘feedback is feedback – not good or bad.’ Feedback is always helpful if it is specific and timely.

This year is turning out to be a phenomenal year for rediscovering myself and identifying my leadership style. A chief year comes with highs and lows. It is important for anyone who is considering a chief year to evaluate why he or she wants to do it in the first place. It is a hard job as it involves A LOT of people skills, so if you are interested in applying, talk to your chief residents to get a glimpse of what the job looks like. Maybe you can even shadow them for a day!

As for me, the next time someone asks me if I did a chief year to improve my applications, I shall just chuckle to myself.

Feel free to ping me @prarthnavb on twitter for comments and thoughts.

 

NEJM Resident 360

December 3rd, 2019

To HBCU or not to HBCU? That Is the Question.

Allison Latimore, MD

Dr. Latimore is the Education Chief Resident at the MedStar Washington Hospital Family Residency Program in Washington, DC

Finding my home

There were a sea of students sitting in the auditorium, and parents were all directed to the balconies. The sound of trumpets began to blare, and the bodies of the marching band swayed rhythmically. Five minutes after soaking in the music, the ambiance, and the liveliness of Howard University, my sister and I locked eyes and decided that we were home.

Historically Black Colleges and Universities (HBCUs) are defined in the Higher Education Act of 1965 (amended) as “…any historically black college or university that was established prior to 1964, whose principal mission was, and is, the education of black Americans, and that is accredited by a nationally recognized accrediting agency or association determined by the Secretary [of Education] to be a reliable authority as to the quality of training offered or is, according to such an agency or association, making reasonable progress toward accreditation.” I was privileged enough to attend Howard University in Washington, DC, which is an HBCU founded in 1867. In high school, I made this calculated decision because I was aware that Howard University was one of the top institutions for educating black medical school applicants in the United States.

HBCU graduates in my family

Finding my career

However, as I matriculated through my undergraduate career and met other pre-meds, I began to realize that some people held the idea that going to an HBCU to prepare for medical school was not good enough. Some underestimated how well HBCUs prepare their students for a career in medicine. Unfortunately, I subscribed to these ideas for a while, due to peer influence, and struggled with the MCAT. It was not until I got a glimmer of hope, in the form of an email from Meharry Medical College, that I believed my dreams could still come true. I was offered an interview for the Master of Health Science Program, which is similar to a post-baccalaureate program. Suddenly, my thoughts of leaving the HBCU world went away. When many other schools said no, Meharry Medical College saw something in me, and said yes.

Finding my “family”

Attending Meharry gave me the same warm feeling as attending Howard. Medical students at other institutions and older physicians have described to me the feeling of being sabotaged or having “gunners” hiding information from others to get ahead. These attitudes did exist at Meharry, but were far less common than other places. No one wanted to see anyone else fail. Each class felt like a family. I never had black physicians growing up, and I surely didn’t know many in my personal life. This was the first time I was surrounded by people who looked like me and had achieved the goals that I was so desperate to achieve.

While I was attending medical school, I heard snide remarks from medical students at other institutions — remarks insinuating that it would be difficult to match coming from my institution. These ideas stem from the fact that outside of the African-American community and HBCU community, many people are not aware these schools exist. But many of my classmates matched into their number one choices at some of the top medical institutions in the country, and so did I.

Now what?

HBCUs are special places where you are, finally, not the “only one” in a room, where there is a wonderful mixture of social and academic life, where you physically see what you are aspiring to be. Unfortunately, not everyone sees the incomparable value of HBCUs. On October 1, 2019, federal funding of HBCUs expired after congress failed to extend it.

This left me questioning the future of black doctors in America, underserved patients, diversity in residency training programs, and medicine as a whole. If three major institutions that educate mainly black physicians (Howard University, Morehouse School of Medicine, and Meharry Medical College) lose federal funding, will our medical system become less representative of our patient population? There are other schools that graduate a significant number of black doctors, such as University of Illinois College of Medicine, Wayne State School of Medicine, and David Geffen School of Medicine at UCLA (affiliated with Charles R. Drew University of Medicine and Science, which is also an HBCU), to name a few, but competition for spots is fierce. I understand that people may say, “Well, minority and disadvantaged students interested in a career in medicine just need to study harder, do better on the MCAT, shadow for more hours, do more research, or simply go somewhere else.” To me, it’s just not that simple.

Fortunately, on December 4, 2019, a bipartisan agreement was reached to fund HBCUs. This proposal includes permanent annual funding of $255 million for HBCUs. HBCUs are wonderful places to get an education for both minority and nonminority students, but they cannot be the only resource for educating minority doctors. How can other institutions help promote diversity in the medical education and residency programs?

I’d love to hear your thoughts in the comments below.

 

NEJM Resident 360

November 26th, 2019

Of Metrics and Medicine

Dr. Eric Bressman

Dr. Bressman is a Chief Resident in Internal Medicine at Icahn School of Medicine at Mount Sinai in New York, NY

One of the least motivating requests I received routinely as a new intern was something like, “… and can we make sure this is a discharge before noon?” I recall a particularly eager nursing manager surveying the resident teams on her unit to gauge our interest in arriving even earlier each morning (5 AM, perhaps?) in order to prepare potential discharges before pre-rounding. We shared a nice laugh.

Administrators vs. House Staff

Hospital administrators and medical interns share many passions, but throughput is not one of them. As residents, we are immersed in caring for, and learning to care for, the patient at hand. Patient flow dynamics is not high on our daily list of concerns. Residents and leadership have not always seen eye to eye, but the discord has ratcheted up in an era increasingly focused on metrics. As with most issues in our convoluted healthcare system, it boils down to misaligned incentives.

When you map out the Venn diagram of what administrators and residents prioritize, high-quality patient care sits squarely in the overlapping center. Outside that, however, are things like throughput and average length of stay on the one side, and sitting down to teach the med student or getting home in time to go to the gym on the other. That isn’t to say that either side doesn’t care about the other’s issues, but, for better or for worse, it’s not what drives their day-to-day decision making. 

Metrics, of course, come in a variety of flavors. There are some where the goal is universally agreed upon, whereas the methods are only variably so. Everyone wants to reduce rates of hospital acquired C. diff infection, and basic methods of preventing transmission jive with common sense. Reducing diagnosis by means of judicious testing is backed by good evidence (Infect Control Hosp Epidemiol 2018; 39:737; JAMA Intern Med 2015; 175:1792), but friction can arise between leadership and front line providers when this becomes an end in and of itself, and the patient in front of us becomes a potential statistic.

Other metrics are less intuitive to residents. Discharges before noon (DBNs) are a perfect case study. Theories abound as to the benefits of DBN for patients (e.g., getting home during the day, ability to pick up meds at pharmacies), but there is no compelling literature demonstrating any of this. This is not lost on residents. One could similarly posit downsides to incentivizing early discharges (holding patients to meet metrics, hurried coordination of services and appointments; NEJM JW Hosp Med Apr 2017  and J Hosp Med 2016; 11:859).

More important are the contradictory incentives at play. Hospital leadership view each DBN through the lens of throughput. The earlier a patient goes home, the earlier a bed opens up, and the sooner a new patient gets a room (J Hosp Med 2015; 10:664). It (questionably) decompresses the ED, and boosts the bottom line (Am J Med 2015; 128:445) . From the resident perspective, in many circumstances, an earlier discharge increases the likelihood of another admission. The reward for working hard to get the patient out early is … more work.

Solutions?

The solution should be obvious. If the hospital’s motivation is financial, then they should pass that incentive along to the residents. Not in the form of pizza parties, but as cold, hard greenbacks. This is how attendings and nurse managers are motivated in many institutions. There is hesitation, it seems, to tie bonuses to residents’ productivity. Despite improvements in resident salaries, we remain underpaid in terms of hourly wages, and there is no calculation of RVUs or talk of overtime pay. Debates over residents’ legal status notwithstanding (N Engl J Med 2011; 364:697), we are influenced by the same basic motivations as every other employee.

This same logic exercise can be applied to just about every point of contention between administrators and house staff. If leadership wants to understand how to get its front-line providers to buy into a particular metric or initiative, they should take an honest look at their own motivations. If it is purely about improving the quality of patient care, then they need only demonstrate that convincingly. If it is driven in any way by profit — which, by the way, is part of the business of medicine — then they should pass it along. Human nature is not to do more work for the same amount of money.

Residents can, similarly, do more to view the world through the lens of the administrator. Leadership is above the treetops, surveying the forest, whereas we are deep in it, hugging a few of the trees. It may mean taking a broader view of the health of a population and of the institution. But until we take the time to view the world from each other’s vantage point, friction and frustration will persist.

 

NEJM Resident 360

November 20th, 2019

Top 5 Tips for Residency Interview Success

Frances Ue, MD

Dr. Ue is a Chief Resident in Internal Medicine at Cambridge Health Alliance in MA.

Four years ago on a crisp winter day, I interviewed at Cambridge Health Alliance’s (CHA) Harvard Primary Care Internal Medicine Residency program. From the warm, cozy dinner of Nepali momos to the thoughtful and inspiring stories shared, I felt like I had found “my people.” Those that were committed to social justice and advocating for the needs of the underserved. This may sound corny, but unbeknownst to me at the time, this was the beginning of finding my personal and professional home. Fast forward to today, and I feel proud to work at a safety-net hospital that truly cares for all. As I reflect on my interview experiences, I would like to share what I have learned as a former applicant and now Chief Resident.

With my residency family! My fellow wonderful, compassionate, and brilliant colleagues at Internal Medicine Residency graduation. Post-graduation plans: Geriatrics fellowship at BIDMC and University of Washington, Wharton Business School, Hospitalist and Rural Medicine fellowship at MGH, primary care, and two Chief Medicine Residents at CHA.

Tips for residency interview success:

1. Clarify your professional and personal priorities.

What is most important to you in life and in a residency program? At this year’s Alliance for Academic Internal Medicine Chief Residents’ meeting, Drs. Stephanie Call and Cheryl O’Malley emphasized the value of identifying the “most important things” to fuel “the fire of passion for work and life.” What fuels your fire? For me, I seek academic rigor within a social justice lens. In addition to becoming an exceptional clinician, I aspire to be a teacher, leader, and advocate and want to create real change for my patients.

2. Reflect on your story.

Why did you choose medicine as a career? What makes you unique and who you are? What has motivated your journey? Why does this residency program fit within your story? Akin to the 30-second “elevator pitch,” it is important to be able to effectively articulate who you are and who you want to become. 

3. Become familiar with the residency program.

Research the program and city that you’ll be interviewing at. And come prepared with questions! Where do residents live, and how do they get to work? What is the cost of living? What is the advocacy or quality improvement curriculum? And most importantly, are residents happy? Interviewing for residency programs can feel a bit like dating, where you’re trying to find the perfect match.

4. Everything is part of the interview

I’m going to let you in on a little secret – everything is part of the interview. This includes your interactions at the applicant dinner, when the Chief Resident asks you how your day is going, and any pre- and post-interview communication. I encourage you to be your best, professional self!

5. Post-interview etiquette: Second looks? Thank you notes?

Last year’s powerhouse CHA Internal Medicine Residency team (PD and APDs, chief residents, and administrators).

As our Program Director and a fierce primary care advocate, Dr. Rachel Stark says, “we have everything we need to know by the end of the day to make our decision. It is up to you to think about whether you have everything you need to make yours.” Second looks are for you to gather enough information to make an informed choice. Likewise, thank you notes are nice but not necessary.

Lastly, you’ve worked hard to get to this point in your medical career. It is an exciting time! Take a moment to soak it all in. Residency training is an opportunity to shape your professional and educational experience. The feeling of finding my community continues to remain central to my choice in residency program and work as Chief Resident. I challenge you to find “your people” that will help you grow and become the best person and physician you can be.

I would love to hear your advice for medical students on the interview trail! Feel free to drop a note in the comments below or tweet at me @UeFrances

 

NEJM Resident 360

November 12th, 2019

Can Minor Changes in a Program Affect Resident Burnout?

Dr. Daniel Orlovich

Dr. Orlovich is a Chief Resident of Wellness at Stanford University

“How did you like it there?” I ask, sitting down next to a new fellow (between bites of a plump sandwich, hoping there is no spinach in my teeth). 

I expect to hear the standard resident talking points — long hours, frequent call, and ballooning student loans. Instead, she surprises me. 

“Do you know how much they charged us to park there every month?”

I frequently text friends who are residents at her previous program. It is a program I respect — complex cases, the right amount of autonomy, meaningful research opportunities, and faculty dedicated to resident development. Things a resident wants in a program and things a quality program delivers.

She continues to list off things that could appear to be so inconsequential — lack of call rooms, cafeteria overcharging and closing early, and being called by her first name by staff in front of patients. I just met her, but I sense she isn’t whining or trying to win a pity award. Instead, she is opening up. Being vulnerable. Speaking trainee to trainee. I dab my mouth with the beige napkin and continue to listen. 

“Do you know how many cavities I have now?!” I perk up and shake my head in disbelief as I finally swallow that bite of sandwich. 

The more I think about these minor things and how they make some residents feel, the more the whole concept begins to make sense.

Minor Things

Most residents I’ve talked to will embrace the inherent challenges of residency. That means waking up early, staying late, and mastering the nuances of a field that proposes intellectual, emotional, physical, and moral challenges. Residency should be challenging. Residents know that it is temporary. But here is the sticking point: Residency shouldn’t have to be any more challenging than that. 

Minor things may be making residency unnecessarily more laborious and taxing than it has to be.

At times, I get the sense that the discussion about resident burnout is centered around large system-wide changes. Such sweeping changes merit careful consideration. However, do talks about the system overshadow and crowd out an additional issue — the minor things? 

Maybe improving resident burnout doesn’t require moving a mountain. Photo allowed with permission from Solving Resident Burnout.

I propose we consider these seemingly inconsequential and minor changes. This is in addition to, rather than instead of, larger changes. Things like getting quarters for laundry, going to the DMV, getting something notarized, picking up packages at the post office and, yes, going to the dentist. 

In isolation, one could view these minor changes as trivial. I can certainly see how it can be taken that way. To be clear, these minor annoyances are not more important than learning to become a physician. But here is the main message — taken in the right context, although the theme is clear: “Your input is valued and we are listening, you are a human being, and we respect you.”

So here is the key question: Are there minor ways in which programs can listen to what residents want and then deliver those things without radically changing the system? This means a residency program may already have allocated the time or money. These minor measures won’t fundamentally change the well-described barriers (culture, leadership, and financial incentives) to improving the system. Nor do these minor changes excuse us from having frank discussions and acknowledging ripe areas of opportunity. However, these tiny steps are a start. They may serve as a small foundation of trust and communication between programs and residents. They may herald a new way of approaching old problems. They may seem more real and tangible. And, they may even be easier to implement, since they offer a way to gradually make changes from within the system instead of retooling the entire system. 

A Recent Study

Are there any data to support using an existing framework to promote resident wellness in a minor way? Let’s look at a recent study of nearly 60 radiology residents (J Am Coll Radiol 2019; 16:221). These residents had 15 vacation days and 12 sick days. That means the program already had these days covered and funded. But here is where it got interesting — the program renamed 5 sick days and instead called them “wellness days.” Simple rebranding. These new “wellness days” could not be used on Mondays or Fridays to extend a vacation. What was the result?

  • The non-burnout group used more wellness days (71%) than did the burnout group (45%).
  • 86% of residents strongly agreed or agreed that “wellness days can help reduce or prevent burnout.”
  • 68% of residents strongly agreed or agreed that “wellness days have had a positive impact on experience as a resident.”

On the surface, these minor changes seem, well, minor. With a closer look, they reflect an expert understanding of the following: 

  • Listening to residents
  • Implementing cost-effective solutions
  • Working within an existing framework
  • Allowing residents the autonomy and freedom to engage in wellness activities of their choice

Take Home

We all know by now how bad resident burnout is. So minor solutions like the one above are reasons for hope and measured optimism.  Of course, minor solutions certainly won’t fix all the structural maladies plaguing our training system. Nor are minor changes ideal. But they are a practical step in the right direction. And it is a step that doesn’t require asking for money, going through 12 committees, or depending on large governing bodies to approve changes.

The main message is this:

  • Residents are on the front line — listen to them, because they may have creative solutions and insight.
  • Solutions don’t have to be expensive or require a dramatic overhaul — the framework may already exist.
  • These solutions may be considered “minor” but may be highly valued by residents and decrease resident burnout.
  • Residents know what makes them well — allow them to engage in activities of their choice. It is not a one-size-fits-all approach. 

And now I’d welcome and encourage your feedback. Would this work or not? Are there any other “minor” solutions that could be implemented?

The post and comments were prepared by the author in his personal capacity. The opinions, views, and thoughts expressed are the author’s own and do not necessarily reflect the author’s employer, fellow employees, organization, committee, or other group.

NEJM Resident 360

November 7th, 2019

Painting in a Visual (Abstract) Medium

Justin Davis, MBBS

Justin Davis, MBBS, is a Chief Resident at Barwon Health in Geelong, Australia.

I’m not creative. I wish I were. I listen to music (with my particular choices being classical and music from video games) and wonder to myself how people are able to come up with such amazing pieces of art and media. I’ve tried it myself. I used to play piano back in med school, before the constant house moving and having to pay to get the piano moved separately and tuned each time made it non-financially viable (my old piano is elsewhere now, and my current time is taken up by way too many non-creative things to realistically pick it back up). I tried to create music, tried to rack my brains to come up with something. But my brains just won’t rack, not in that way. In a similar fashion, I don’t learn in a visual manner. I’ve seen people draw beautiful flow charts and mind maps while they were studying, but mine are simply walls of text with nary a colour, paragraph, or picture in there. It’s just how I work.

Which brings me to today’s topic and why I find it rather fascinating that use of the visual abstract is increasing in social media to create engagement as well as to disseminate scientific information. If you haven’t heard of visual abstracts, it might be because they are a relatively new thing — only a mere 3 years old. They were first coined by a clever chap by the name of Andrew Ibrahim who showed that use of these constructs on social media platforms increased engagement with the post compared with a simple text-based design, despite them carrying essentially the same information. (Regular readers of my blog posts may have noticed there’s a social media theme here once again. In my earlier discussion of the Nephrology Social Media Collective (NSMC) and the fantastic work they do promoting free online medical education through social media, I failed to mention that the NSMC has strongly taken up use of visual abstracts and are actively teaching others how to make them.)

When you stop to think about it, why wouldn’t visual presentations be better? How many of us have stood there, bored in a line, waiting for coffee or public transport or whatever it might be, and scrolling through Instagram or Reddit? These platforms are visual places. Things catch your eye, and you stop to read more about them. It’s so much easier to blithely scroll past several posts that are just blocks of text than it is to pass something that is colourful, creative, and (especially in our case) conveying important results of the study in an easily digestible fashion. A social media platform can be used for some amazing online education, but it is the same platform that can be shallow and cause your personal presentation to be easily missed if it’s simply conveyed in text. And we wouldn’t want that, now would we?

This way of disseminating information is becoming increasingly common. You may have noticed The New England Journal of Medicine, for example, doing just that. A quick perusal of NEJM’s twitter feed reveals several visual abstracts pertaining to some recent articles, such as the article about transcatheter aortic valve replacement in low-risk patients, to pick one example. The same information as the text. A better style of presenting it.

An example of a visual abstract I’ve done for an ongoing manuscript (hence the removal of certain pieces of text. You understand).

You might wonder why I talked about creativity at the beginning of my blog post. One reason — I like to start my post with something relatable (although I’m sure many of our constant readers are much more artistically talented than I am), but another reason was to convey that I don’t think you have to be creatively minded to design and produce an engaging visual abstract. Don’t get me wrong — it doesn’t hurt! I’m sure the ones I have created have terrible colour choices that clash and a layout that definitely could be improved on with some creative flair. But despite my total lack of creativity, I can still produce an abstract which is probably kinda ok. Because, like reading and playing music, they follow a structure (which again, I’m sure others can and have improved on, but my type A personality brain just doesn’t stretch in that fashion) to convey their information, which can be replicated. And while there is a learning curve as to what is/isn’t important and how to convey information in a minimalist manner, once you get the basic components of it down, it’s definitely something many people can pick up and use to produce amazing work. You can even make them in PowerPoint, that staple of presentations everywhere.

I’m fortunate once again that during my NSMC internship, I was mentored in the use of visual abstracts, and completed a project in which we produced them for various publications and honed our skills. I’ve even started to incorporate them into my manuscript submissions to journals as I feel that such things only serve to strengthen a paper (please see one slightly redacted version here — it’s a work in progress). I certainly find them a lot easier to read and engage with on Twitter or other social media platforms. And perhaps you do, too? (It’s slightly ironic, isn’t it, that I’ve written a wall of text in order to champion a simple minimalist visual format? Ah, well).

“You can see everything. You can unsee nothing.”

NEJM Resident 360

September 5th, 2019

Building Your Squad — Residency and Beyond

Ellen Poulose Redger, MD

Ellen Poulose Redger, MD, is a Chief Resident at Stony Brook University Hospital in Stony Brook, NY

At nearly every stage in our education and training, we find “our people.”  Maybe it’s your table-mate in kindergarten, or the kid with the really cool light up sneakers in preschool who becomes your best friend.  Maybe it’s your next-door neighbor who you play with after school, or a coworker from your first job in high school.  These people become part of our squad — even if their membership is only transient in this long journey of life.  What I’d like to talk (write) about though, is finding your squad in residency.

Match Day, MS4 year:

You nervously check your email or open an envelope to reveal your fate for the next 3-7 years.  After all the emotions of where you matched happen in rapid cycle, you think, maybe for a minute — who else is going to be there with me?  What happens to my best friends from med school — the ones I spent evenings and nights and weekends with in the library, and the ones who have been with me through the rough rotations and the brachial plexus and the formaldehyde and everything else?  How on earth will we move away from each other and be busy interns and stay in touch?  [Note to all MS4s — it’s called a group chat, and sometimes you put it on “no alerts” when you’re busy, and sometimes you realize you have 86 missed texts from these people, who will always be part of your squad.]

 

Orientation to Intern Year:

Everyone shows up, early, on day one and everyone is full of first day jitters.  Maybe you’ve moved to a new city or even a new country, maybe you’re still at the same place you went to medical school.  Regardless, you’re a newly minted doctor in a room filled with strangers, people you’re about to be in the trenches with for several years.  Everyone’s sizing each other up: who’s going to be the social chair?  Who’s the gunner?  Who’s the one who will have the bag with acetaminophen and ibuprofen when you get a migraine at work?  Who knows how to use this EMR system already?  If you’re anything like me, you’re trying to settle into a new apartment and figure out how to drive around a new city and do basic things like get groceries, while at the same time trying to make friends and a million other things.  You sit through hours of orientation (retirement accounts?  I haven’t even gotten a paycheck yet!  ACLS certification?  Controlled substance prescribing training?  I’m barely ready to give a colleague that ibuprofen I carry around, let alone give a stranger anything stronger!)  You might go on a retreat with your intern class.  It may or may not be a scavenger hunt with insanely hard clues.  But, by the end of these few days — you’ve found some people.  The ones you will be able to call a year later and go on a spur-of-the-moment “we have to go get a coffee or something stronger together before I go insane” date with.  [Note to all interns — these residency BFFs don’t have to be in your program, in your year, or necessarily even doctors at all, but you’ll need someone.]

Sometime in the Middle of Your Training:

Depending on what specialty you’ve entered, this may be your 2nd-5th year of residency.  You’re an old pro at things that used to scare you (ACLS and codes, anyone?), have navigated several rounds of medical students and new interns through the EMR, and calmly know how to push metoprolol to control afib with RVR.  You’ve learned how to have the difficult conversations on the phone at 2am with patients’ families, learned and forgotten more than you ever thought possible, and probably left the hospital at least once with the bodily fluid of a patient on you.  And you’ve done all of these things with a group of colleagues — friends, actually — who you literally can’t remember not knowing.  [Note to mid-term residents — this is a good thing, not a sign of early onset dementia.]

Panicked Thoughts in the Last Months of Residency:

Similar to how you felt many moons ago as a MS4, you’re now going to a fellowship or a “real” job as an attending somewhere, and again, you’re (I’m) nervous about how this is going to go.  Everyone I’ve been working with for years is moving on to something new, and many of us are also moving to somewhere new.  Again — how are we going to stay in touch?  How will we stay so close when we don’t see each other for months on end?  And, of course, what about the people at the next place?  We’re embarking on the next step in our journey, but, again, when we disperse across the country or across the globe, how will we stay connected?  [Note to new attendings — Again, it’s technology and social media: texts and direct messages and conversations entirely in memes.  And hopefully using vacation days to go see each other or meet up in a cool place.]

In each of these steps in our professional lives, just like in preschool and elementary school and every step before we made it to “being doctors,” we find our people.  The ones who it isn’t weird to text and ask for recommendations on compression socks.  Or the ones who you’ll complain to and get advice from when your career and personal plans diverge.  These people will be your squad, which will grow and shrink over the years and have people like your high school BFFs and your med school BFFs and your college BFFs and your residency BFFs and so many more people in it.  Because you’ll need a person you can ask for compression sock recommendations, but also someone who can recommend a good book for pleasure reading and also someone who can send you a great meme with uncanny timing when you’re having a rough day.  The days (and nights) might be really long in training, but the years are short — and they’re all so much easier to get through with a good squad at your side.

NEJM Resident 360

August 28th, 2019

Status: Post-Residency Syndrome

Ashley McMullen, MD

Ashley McMullen, MD, is a Chief Resident at UCSF in San Francisco, CA

Today, I’m thinking about the end of residency. But first, let me tell you about the beginning of residency. My first day of clinic, my very first week of residency, I had a grand total of one patient scheduled. A seasoned outgoing resident had given me sign-out on this person, along with some big, knowledgeable shoes to fill. I did my most thorough pre-rounding the evening before. I prepped my note and reviewed the problem list I intended to cover during our visit. Our encounter began with some pleasantries, followed by my well-rehearsed, “What brings you in today?” To which my patient replied, “I really just need these forms filled out by a doctor.” 

“Easy enough, I got this!” I thought to myself. Then I noticed the systolic blood pressure that was charted in the 60s. Suddenly I was staring more closely at the ashen skin, sunken eyes, and listless movements in front of me. However, when asked about this, my patient smiled and shrugged me off like I was hallucinating, then gently pushed the forms towards me. We agreed to start with a brief exam: pale conjunctiva, fast, regular heart beat, exquisitely tender abdomen, with overlying skin that was inflamed and indurated. I proceeded to check my own pulse which was racing, and then left to find an attending. Less than 1 hour later, my patient was admitted to the ICU with septic shock from a large abdominal wall abscess.

 

I spent a lot of time ruminating on what I could have done differently. Why didn’t I call to check on this individual before the appointment? Why didn’t I notice the blood pressure sooner or get an attending faster? What if the resident who signed out to me finds out their former patient ended up in the ICU after one visit with me? Thankfully, that patient ended up being okay, but it was the first of many experiences that would leave a lasting impact.

UCSF Internal Medicine c/o 2018 on the last day of intern year (1st year of residency training)

 

Residency is an interesting phenomenon. It’s like an invisible threshold, where on one side of July 1 you are light and buoyant. On the other, you are weighed down with the responsibility of people’s lives ostensibly placed on your shoulders. Few professions can match the physical and emotional peaks and valleys that define medical training. Friends and family that aren’t in medicine can find it hard to relate the day-to-day life of a resident. Many times, I would come home to random questions about dramatic traumas or steamy call-room encounters (thanks, Grey’s Anatomy!). Therefore, many times, I would have to explain the role of an internist — that most nights, I’d be lucky just to see the inside of a call room. If I did lay down, it was at the risk of being jolted awake for anything from a cardiac arrest to an FYI page about rabbit allergies.

UCSF Internal Medicine c/o 2018 nearing the end of residency

Currently around the country, thousands of newly matched interns are eagerly crossing that proverbial threshold. On the other side, there awaits experiences that will test the boundaries of their comfort zones and leave them equal parts exhausted and fulfilled. They join other new doctors from various walks of life and form the unyielding bonds of friendship fortified by the shared experience of residency. To borrow the famed quote from Charles Dickens, it is the best of times and the worst of times; and those of us who have already crossed the boundary must continually weigh the virtues of rigorous medical training against the long-lasting impact on physician well-being.

 

As for myself, I have now started my first “real” job since 2011. It’s been an exciting process, but one in which I’ve also had to grapple with my own post-residency syndrome. I look forward to taking some time off to spend with loved ones and reclaim some parts of myself that didn’t quite make the full journey across the threshold 4 years ago. 
NEJM Resident 360

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