Insights on Residency Training

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

During the first week of the U.S. national vaccine rollout, news outlets reported a protest after a major medical center’s initial COVID-19 vaccine distribution list did not include almost the entirety of their house staff. Less publicly, I have heard about additional instances across the country where trainees as a whole have been or felt excluded from receiving a dose from the first shipment of vaccines. A common trope among the stories in which the slight was accidental has been that, somewhere along the line, nonmedical staff misunderstood the role of medical trainees in patient care, did not know where they belonged administratively, or in one case, did not know the difference between residents and fellows and inadvertently left the former off the communication, even though a substantial number actually were due to be vaccinated.

Hearing about such clerical errors reminds me that the hierarchy of academic medicine is not intuitive to those outside of the field. For the most part, the result of this is fairly benign, and usually results in explaining things to friends and family (such as the difference between residency and fellowship, or that, as an internist, I haven’t delivered a baby since medical school). For patients, not understanding the hierarchy can create confusion and even frustration. They want to know why they need to wait to meet the attending physician in a teaching clinic, or why they can’t get a medication refill after discharge by the resident who took care of them in the hospital.

Doctor at Walter Reed National Military Medical Center receives a COVID-19 vaccination. Dec 14, 2020. (DoD photo by Lisa Ferdinando) CC BY 2.0

Residents and fellows can also be negatively affected by others misunderstanding their role. Their confidence can be shaken when a patient demands, “I want to see the doctor,” when they enter the room (not knowing that they had been mislabeled as a student); or they might feel alienated if they don’t have a workspace on a rotation because they are not formally employed by that department. Building up over time, these types of seemingly harmless encounters make many trainees feel like they do not belong or are not appreciated in the place to which they devote so much of their lives. Unfortunately, these perceptions were amplified for those who were not included in the COVID-19 vaccine rollout, no matter how unintentional the slight(s) may have been.

So, what will help trainees trust that their programs, institutions, and patients value and respect them? After reflecting on my own and my peers’ experiences in their programs, transparency, equity, agency, and recognition appear to be fundamental. Some suggestions of ways to implement these principles include:

• Deliver honest and consistent communication about operational matters directly to house staff.
• Offer the same opportunities to trainees as are given to hired employees (e.g., retirement matching, health benefits, vacation time, and appreciation weeks).
• Ensure residents and fellows understand where they fall in both the educational and administrative framework, such that they are aware of all the channels by which they can direct questions and advocate.
• Include residents and fellows in institutional initiatives that affect them.
• Devote time during orientation of nonphysician employees to the structure of medical education. Ensuring that other healthcare providers and administrative colleagues understand the different roles of physicians will not only improve teamwork, it will also help them communicate with patients on our behalf.
• Recognize trainee efforts and accomplishments publicly.

These measures not only contribute to wellbeing and morale, they also engender a higher likelihood of retaining the resident or fellow after training.

One of the lessons I have learned in my short time thus far in program leadership is that sometimes asking how we can support is as important to intuitively providing support. The vaccine rollout has sparked meaningful conversations about what it means to feel valued and respected in one’s place of work, particularly as a trainee. My hope is that the dialogue continues beyond the pandemic and results in lasting change.