Insights on Residency Training

Dr. Braunthal is a Chief Resident at the Cleveland Clinic Foundation in Cleveland, OH.

Starting Our Garden

Last year, my boyfriend asked if I wanted to join a community garden. As he handed me the paperwork, he said he would be the “primary,” I would be listed as a “helper,” and for only $10, we could grow our own vegetables. Distracted by whichever rotation I was on, I agreed without much thought, assuming that “helping” would be something similar to a community service project. To me, a garden was some sort of greenery that already existed, occasionally needed upkeep, and in this case, would result in a crop-share. Needless to say, I was a bit confused about his fixation on choosing seeds and pre-planning the garden. I was even more surprised when we walked over on a misty mid-March afternoon, arrived at an overgrown 10 x 10 foot plot, and was told we needed to start weeding by hand.

Community gardening has provided a welcome source of activity and [distanced] socialization during the COVID-19 era. It has also inspired much reflection at a pivotal time in my career: the start of the pandemic, the end of residency, and the transition to chief resident responsibilities. Naturally, I have drawn parallels between them all.

Gardening (and Residency Training) Best Practices

To begin, like in medicine, best practices in gardening are hotly debated and change over time. As gardeners prepared their soil in March and April, they had seemingly endless conversations about the risks and benefits of tilling the soil, a practice that can be both beneficial and disruptive to soil health. My only contribution was telling the gardeners that they sounded like my fellow internists, grappling with whether the updated hypertension and aspirin guidelines could be applied to all of their patients, or to only those who were similar to the cohorts studied in the landmark trials. For those curious, we lightly tilled this year, added leaves to increase the organic matter, and will be doing “no-till” for the future. I am still not sure which strategy is the standard of care.

With our newly enriched soil, we were ready to plant. We had packets of seeds, shoots to transplant from one of my co-chiefs, and numerous gardening books from family members. We followed the instructions about depth, distance, and watering frequency. Then, we realized that, like patients, plants do not follow the textbooks.  Similarly, their outcomes rely heavily on their environment. For example, our five kale plants were growing at equal rates for the first few weeks until the butternut squash vines took over a third of the plot and started blocking the sun. Then, the kale plant that had the most sunlight and rain grew the largest, and the others have been lagging behind, only to grow when we move the leaves out of the way. Competing weeds initially suppressed the carrots; once they were removed, the carrot stems shot right up. On the other hand, the corn, squash, and tomatoes have grown in spite of everything.

Structure Affects Function

A principle that is fundamental, but not unique, to medical education is that structure affects function. An example from residency that stands out is how adjusting one of our subspecialty rotation’s call schedules garnered better continuity of care, which ultimately engendered improved resident performance and morale. Even within our first month, my co-chiefs and I have observed residents’ successes and struggles. We are learning how to optimize our program’s infrastructure so that it can benefit a diverse group of learners. Just as my boyfriend and I figure out how often to water, weed, pare down, and transplant, my chief group is recognizing how to appropriately intervene and when to implement systemic change.

One of the most valuable aspects of starting this garden at the beginning of my chief term has been the unique opportunity to revisit the uncertainty, vulnerability, and insecurity that accompanies being a new trainee. In the garden, I am the intern, or maybe even the first-year medical student, navigating a new environment and grasping the vocabulary of an entirely foreign vocational language. My boyfriend and I constantly ogle our neighbors’ more aesthetically pleasing plots. Until recently, we assumed that others had years, if not decades, of experience. Much to our surprise, some of them only started last year. The imposter syndrome reminds me of being an intern, when becoming as knowledgeable or efficient as a senior resident seems like an unattainable dream. Yet, I can see the same pride from these new second-year gardeners that I do in our new seniors, and that I did in myself, realizing that they can independently manage a team and care for patients in a way that they did not think was possible a year earlier.

Growing Confidence

It is now early August, and we are starting to reap the fruits of our labor. The garden is growing on me. Although I wax poetic about the reflections it has inspired, the reality is that I was not enjoying it until I began to understand how and why things are done. Aside from a delayed appreciation for anatomy lab, I initially could not think of a parallel feeling during my medical training… then, I remembered I almost quit before it even began. Midway through sophomore year of college, I had a sudden insecurity that I would not be able to get into medical school, which took the joy of learning out of any pre-med class that I was taking. I decided to take a semester to explore the myriad other intellectual avenues offered at small liberal arts colleges, later stressed about finishing the pre-med requirements before graduation, and subsequently enrolled in two biology and chemistry summer courses at a university closer to home. Whether it was a different teaching style, living with my family, or the exhilaration of being in a new school, something clicked. I left for study abroad confident in my ability to become a physician and returned to college that spring, eager to jumpstart the rest of my career. As for many in medicine, my journey has since been filled almost daily with peaks and troughs. Harnessing the reinvigorating moments has kept me going; the desire to teach others how to do so is part of what inspired me to become a chief resident. I look forward to the day I can bring some homegrown vegetables to guide the conversation.