Insights on Residency Training

Dr. Temte is a Chief Resident in Internal Medicine at Providence Portland Medical Center in Portland, OR.

Even before starting residency, I knew I wanted to be a critical care doctor. I chose my residency program and drove halfway across the country to get a solid hands-on clinical experience. As an intern in the ICU, I was eager to get involved in every possible way. One morning after team rounds, fully caffeinated and ready to call a few consults, I heard the speakers sound, “Code Blue, CCS 9.” I immediately dropped everything and ran to the room. This was the 31-year-old man I had just admitted for a polysubstance overdose.

Deer in the Headlights

As I arrived at the code, I could see my attending standing in the doorway. The nurses started chest compressions, and the usual chaos was all around. Alarms were screaming, and a desperate family was standing outside the door. As I approached the room, my mentor and attending turned to me and said, “Are you ready?” I nodded and took a breath. He turned to the rest of the room and stated loudly, “Alright, everyone, Dr. Temte is running this code!”

I memorized algorithms and watched numerous codes, but this was my first time as the leader. I assigned roles, gave the first shock, and ordered a dose of epinephrine. My heart was racing out of my chest. My attending turned to me and asked, “What now?” I completely froze. Everything I had learned melted away, and I had no response.

Overwhelmed, I took a step back. I’m sure I was white as a ghost. My attending confidently took back lead of the code until the patient had a pulse. “What on earth just happened?” I muttered to myself.

Success in Failure

Later that same day, my attending found me in the call room. He said something unexpected. “Great work in there!” In a frustrated tone I responded, “I totally failed! I froze after a minute. I thought I was prepared for this.”

He responded, “Now that you’ve felt the weight of the room, you’ll know what to expect next time. That’s how everyone’s first code goes! Putting yourself out there the first time is the hardest part.”

This was a pivotal moment in my career, and I learned an important lesson that day: Active learning in a safe environment is key to adult learners becoming excellent clinicians.

We regularly find ourselves in new situations throughout medical school and residency training. However, we also start our early careers in an environment where performance is being constantly evaluated. Fear of appearing incompetent or unprepared can limit the desire to seek novel experiences. At times, we would rather lean back on our comfort zones of a perfect patient presentation or an already well developed clinical framework. Psychological safety is the belief that members of a team have a safe space for interpersonal risk-taking¹. This protected space welcomes learners to push their boundaries and be active participants without fear of negative consequences.

Creating Psychological Safety

Throughout my career as a resident and now an attending, I’ve seen excellent clinical and interpersonal skills develop alongside discomfort. As adult learners, especially in residency, we need to be active participants in the challenges we face. Utilizing a growth mindset requires leaning into the discomfort at times. The first hypotensive patient you take the lead on will inherently be uncomfortable. If done in an area of psychological safety, these early experiences can provide the firsthand experience to acquire excellence.

That day in the ICU, running my first code, my career took a large step forward. I realized the importance of the support I received. The nurses, senior resident, and attending saw my desire to improve, not the skill gaps I was so self-conscious of displaying.

Creating a space with psychological safety requires intention. Preparation prior to the encounter is key to confronting new situations with confidence. Pre-briefing with all members of the team regarding roles and duties can help with learner comfort. To the learners, be clear regarding what you are specifically working on so the other leaders on your team can allow room for growth. To all those about to step into a senior resident or attending role, set the stage early by setting clear expectations. Explicitly call out the safe learning environment.

Medicine is a demanding profession, but we all deserve a safe space for active learning to become excellent physicians.

1. Edmondson AC. The fearless organization: Creating psychological safety in the workplace for learning, innovation, and growth. Hoboken, NJ: John Wiley & Sons, 2018.