Insights on Residency Training

Ahmad Yousaf, MD, is the 2015-16 Ambulatory Chief Resident in Internal Medicine at Rutgers New Jersey Medical School.

As my co-chiefs and I try to figure out how to best serve our residents and deliver a worthwhile education to them, I have begun contemplating what it is that really motivates doctors in training. What is the driving force behind a resident striving to be a more knowledgeable clinician? How do we convince them that they need to work hard and take an immense amount of time and exert an enormous amount of effort to acquire both the didactic knowledge and the clinical sense required and expected of them by their profession and patients?

After a lot of thought and discussion with colleagues, I have found that the drive for each resident is a unique combination of 4 major factors; every resident’s makeup varying the exact ‘amount’ of ingredient that needs to be tapped into to make their training experience worthwhile and productive:

• Fear/Guilt… That knot in the pit of your stomach… that globus sensation that makes it impossible to swallow… that nightmare that wakes you up in the middle of the night as you replay all of the things you missed earlier in the day. It is the fear of killing someone — a drive that is so potent that it leaves residents googling the side effects of the Benadryl they just prescribed as they sit on the toilet between bouts of irritable bowel syndrome at 2AM. This fear and guilt is healthy, but, if not tempered at the beginning of residency, it can be all consuming and harmful. It is a powerful motivating factor when you recognize the immense responsibility that you have — that your order might permanently change the lives of another human being and his or her family.
• Signs that your resident is highly motivated by fear/guilt:
  • Twitchy and nervous on rounds
  • Frequent bathroom breaks
  • Checking and then rechecking orders and notes the way Jack Nicholson checks his door locks in “As Good as It Gets.

• Shame… Do you remember when the teacher called on you and asked you a question that you definitely should have known the answer to, and you froze? Can you recall how you felt the warmth of embarrassment crawl up your chest, pass your palpitating heart, move through your almost completely closed throat and into your now red cheeks? Do you recall the deafening silence that you were responsible for weighing down on all your peers, and the 9-month-pregnant pause your teacher allowed to mature into a full-grown baby of shame and self-loathing? Do you remember thinking about that time over and over again and re-living the terror of that moment of humiliation? That is the moment of shame that drives some of your residents to read, to work harder, and to always be prepared.
• Signs that your resident is highly motivated by shame:
  • Crumpled up notes in overstuffed white coat pockets
  • Coming to the hospital 2 hours before the next resident for pre-pre-pre-rounds with multiple cups of coffee on board before the team attending has even rolled out of bed.
  • Overly concerned about evaluations that peers and attendings spend about 4.7 seconds of mindshare completing.

• Ego… or the Id, if you want to get all Freudian on me. It is the impulse to want to be the best and to triumph over all others. This is the drive that makes you seek the admiration of all, the respect of those beneath you, and the recognition of those ethereal beings we know as attendings and administration. It is the desire to attain a status in which you can look in the mirror and say you did it and declare to everyone, or sometimes nobody but yourself, that you are the epitome of what a doctor should be. I also take the liberty of placing attainment of loftier position/money in this category of motivation — i.e., fellowship and dollar bills.
• Signs your resident is highly motivated by ego:
  • Aspiring cardio fellow (likely a ‘gunner’ intern) that walks around with calipers in his pocket despite being on an outpatient rheumatology elective.
  • Pristine white coat over an Armani suit, far too much hair gel or the clickiest shoes in town.
  • The resident who takes every opportunity to quote obscure papers from Scandinavian research cohorts written in the 1950’s that almost never pertain to the patient or patient population at hand. Impressive? Yes. Clinically applicable? Never!

• Vocational Aspiration… Close your eyes and think about the physician you always wanted to be like. The one who gets down to eye level with his/her patient, speaks confidently about the matter at hand, shows love and compassion that cannot be faked or learned in a textbook, and exemplifies the characteristics of a healer. You see this in the resident who has taken medicine on as a vocation… as a calling. It is who they are and as a consequence, they take it as their responsibility and duty to strive for well-rounded excellence because, to them, there is no other option. This is the drive we strive for but only catch glimpses of when we are not devoured by our fears and shames and egos. If you ask every resident why they do what they do, they give answers that fall into this category: “I want to help people.” “I want to make people better.” “I want to make myself a better person and doctor.” It is what we write in residency application essays but seldom see in ourselves while in training. This is the most important motivator to trigger and mature in the residents we work with. All of the others are important tools to get people going, but without this, we are producers of machines and not physicians.

Factors/Motivators that deserve an honorable mention:

• Golden Child Syndrome
  • “My parents made me do it.” You know these people. They were told what to do and are good at being told what to do.
• The Challenge
  • The intellectual challenge of medicine drives so many physicians. The puzzle that a clinical case represents can be enough of a driver for some residents.
• Silencing the Naysayers
  • There are some who do what they do because they have been told they cannot do it. Medicine…then Mt. Everest. See Ego for further detail.
• The Narcissist
  • “Let me take a selfie while I sew up this laceration like a plastic surgeon.” Are you noticing an ego trend?

There are probably tons of other motivators you see that get people going. Share them in the comments and tell us the tell-tale signs that come with someone who is motivated by that factor.

~Yousaf