Insights on Residency Training

Dr. Bergman Lewis is a senior resident in Pediatrics at Seattle Children’s Hospital. By way of introduction, I am finishing my pediatric residency at Seattle Children’s Hospital, have enjoyed being a resident editor of Journal Watch Pediatrics and Adolescent Medicine for the past 3 years, and will write as an interim blogger for the next month or so. Greg left big shoes to fill but I’ll do my best to pave the way for the next resident blogger.

I am in the agitating phase of studying for a test — I am loosely aware of what looms ahead but have not strategically plunged into studying. The General Pediatrics Boards are about 5 weeks away. Similar to my view of all standardized tests, I’ve dreaded this test since the first time I heard about it. I have been trying — with varying levels of success — to adapt the “right” attitude: Focus more on learning material that I think a “good pediatrician” should know and less on being bitter about how much it costs. (The worst part about failing is that I’d have to pay again next year!) 

Given my imminent trip back to the books, I have been reflecting on how learning happens in medical school and residency. Before I entered medical school, I was involved in launching a middle school where I taught sixth grade for 2 years. At the Seattle Girls’ School, we taught an integrated curriculum. For example, the first trimester’s theme was inventions, and core subjects like reading and math were taught under this umbrella theme. We explained to parents that by mirroring how we learn naturally, neural connections are made, and students stay passionate about learning. 

When I entered medical school, I experienced an environment that was quite far from facilitating natural learning. In fact, the first year of medical school took the most natural “integrated curriculum,” — the human body — and artificially broke it down into histology, pathology, anatomy, and biochemistry. Without a strong science background or honed study skills, I struggled and barely eked by in my classes. It was not until clinical clerkships that I started to believe I might be smart enough to be a doctor. As I began caring for patients, the connections I couldn’t make from a PowerPoint presentation began to appear. I often wish I could go back to the first 2 years of medical school now that I have a scaffolding of patient encounters on which to hang my knowledge. 

Learning in residency looks different than it did in medical school. For those like me who learn from hands-on patient interactions, there is endless material, but little time to process it. Although it may feel more comfortable to learn from a prepared noon conference lecture, do you learn more from the patient care call that causes you to leave the lecture? The answer to where this sweet spot of learning and hands-on experience lies is a moving target, and different for all of us. 

The intensity at which our highest quality of learning occurs is another variable. Some of us may absorb information best when presenting a patient on rounds, voicing a plan despite being less experienced than anyone in the audience. For others, being in the hot seat short circuits all neural connections. During residency, I experienced some of my best learning when I was post-call on rounds but had gotten at least 30 minutes of sleep (this has interesting implications for new work hour restrictions that may take people off post-call rounds). 

The fact is, we all learn differently and most of us spend much time worrying about if we are learning enough. If only we’d give ourselves a collective break. We are all naturally curious people who want to be the best doctors we can be. We cannot help but learn. We should have a bit more faith in the process and trust that when we’re spit out the other end of residency, we will have acquired enough knowledge to be good doctors. 

Of course, our formal training represents the tip of the iceberg of what we will eventually learn. It does seem like developing good learning habits from the get-go is important. For this reason, in residency we should be paying as much attention to how we learn as what we learn. For what it’s worth, here’s some advice for learning that I wish I’d been given: 

• Set up habits that encourage, and don’t squash, your natural curiosity: Look up answers to your questions, not just subjects you are instructed to read about.
• Break learning down into small nuggets. Small nuggets of learning add up and the more you crack open the book or open the online journal, the more habitual and less cumbersome this process will feel.
• Pay attention to what learning medium works for you. Do you prefer print or online material? Are lectures more helpful? When possible, study material in the right medium for you.
• Select one patient per rotation and write down what they taught you.
• Start some sort of filing system for helpful articles or handouts — even if it’s just Google Docs or a box.
• Register for free e-mail alerts from Journal Watch. Read the rest of the relevant Journal Watch publications when you can — the format is perfect for residents and provides brief summaries of relevant studies and take-home messages provided by well-respected clinicians.
• Convert the time you use asking yourself if you are learning to try some of the above suggestions. And by the way, the answer is yes, you are learning a lot…enough.

As residents, one thing we do is try hard. So, we will try hard to keep learning and trust that we are learning while caring for patients. Speaking of trying, I need to face the music and set up a study schedule for Boards so I can get it over with. I will try and stay focused with the right attitude and view studying as a last episode of a sitcom when I will revisit the patients I have encountered in training. Now, if I can just figure out the right soundtrack. . .

Dr. Bergman Lewis is a senior resident in Pediatrics at Seattle Children’s Hospital. By way of introduction, I am finishing my pediatric residency at Seattle Children’s Hospital, have enjoyed being a resident editor of Journal Watch Pediatrics and Adolescent Medicine for the past 3 years, and will write as an interim blogger for the next month or so. Greg left big shoes to fill but I’ll do my best to pave the way for the next resident blogger.

When my daughter, Anya, was a few months old, I remember reading a blog post to my mom that I found when, for the first of many times, I Googled “baby bedtime routine.” One father wrote: “The solution to bedtime is that I crawl in the crib with my baby, then when she is asleep, I crawl out.” My mom and I laughed and rolled our eyes. Fast-forward 1 year and I’m blearily gazing into the crib, patting Anya to sleep, wondering if it would hold my weight. Sleep is only one area in which being a mom has humbled me and challenged the tenets of my pediatric education.

When the time to expand our family coincided with the last year of my residency, my husband and I knew it was not going to be easy. However, I did not foresee all the ways it would shape me as a physician. As a pediatrician-in-training, I knew the “right” advice to offer in each situation, but it turns out that the “right” advice carries little weight in the minute-to-minute nuances of parenting.

We found our stride as a family only when I started accepting that we would have our own unique challenges as well as our own solutions and started doing what worked for us. We hunkered down and my world became very narrow — hospital or home. My husband and I tried to listen to each other and tune out all the “shoulds” that made us feel inadequate. We were blessed to have local family and actually moved in with my mom for the year. The bills piled up and the voice mailbox filled. We co-slept, not for philosophical reasons, but because it felt necessary. I was tired and couldn’t spend the precious time at home with Anya listening to her cry from the other room. Anya stayed up late when I was on the wards and slept all afternoon with me post-call. When I was on nights, we took two daytime naps together. This was not the sleep-nap routine I had outlined for parents in clinic, but Anya’s adaptability gave us long hours together snug in bed, breast-feeding after 30 hours apart. By paying attention to Anya’s cues instead of outside advice, we found our own rhythm and Anya thrived — and my husband and I survived!

Once I became more comfortable in our own ever-changing “routine,” I began to recognize allies within medicine. I felt less isolated as I shared more about our solutions. After attending a Grand Rounds presented by the medical examiner on the dangers of co-sleeping, I sheepishly admitted to my intensive care attending that we spend the majority of time co-sleeping. “So do I,” she responded, “you have to when you’re away so much, right?” The fellow and the pharmacist both chimed in with their own stories of co-sleeping. It felt like we were talking about brewing gin during Prohibition.

My own experience adapting to motherhood while being a resident convinced me that our job as primary care doctors is to lay out the safe — but wide — framework within which patients can find their own path. It is tempting to preach guidelines and be quick with advice but more valuable to tailor our expertise to empower individuals to find their own way. Particularly in light of my experience as a parent, I will strive to have conversations with patient families that are nonjudgmental, honest, and practical.

I salute my fellow resident parents out there. Keep up the good work crafting a home life that is uniquely right for your family. I would love to hear your stories from the trenches.