For many graduating medical students, the prospect of residency can be daunting. With increased strain on medical systems, the expectations heaped upon those going into the vocation of medicine are high. Although residency offers great opportunities for personal and professional development, the strain associated with the work and responsibilities, if left unchecked,can result in burnout of young medical professionals.
In its fourth edition, Staying Human during Residency Training: How to thrive and survive after medical school (University of Toronto Press), by Allan D. Peterkin, offers graduating Canadian medical students insight into the potential hazards of a residency, as well as sound advice on how to recognize problems and overcome the challenges they’ll face. Here, Dr. Peterkin answers e-mailed questions about the book.
Q: What is the most common mistake graduating medical students make, when choosing a residency program?
A: I think most students are pretty careful when choosing a residency specialty and location to study. I would encourage them to find out more about how well the residents are taken care of in terms of wellness programs, compliance with frequency of on-call regulations and the availability of mentoring programs. I would also tell them not to let money be their first priority because they’ll lose interest and compassion over time.
Q: In chapters four and five you discuss ways to maximize supports and find balance, and to protect personal and professional relationships, highlighting what residents can do for themselves, including recognizing signs and symptoms of problems, prevention strategies, as well as setting up support groups. Have you seen evidence that residents have been taking your advice?
A: It’s my impression that residents are starting to take better care of each other and are less aggressively competitive. The hardest thing when I was a resident was pretending that you knew everything and that you never felt stressed or overwhelmed (what some have called the “cloak of competency”).
A really nice example of change is the “Neighbourhood Watch” model at the University of Ottawa, where trainees are actively encouraged to look out for each other, offer support or cover for each other when necessary. The help is never intrusive but always on offer.
A new generation of attending physicians have come to expect balance in their lives rather than complete stoicism and are thus less resentful when their students try to do the same.
As well, I think that the increasing numbers of women in medicine have challenged the “macho model” and this has humanized training for both men and women.
Q: In chapter eight you discuss the ethical challenges that can face residents and ways to overcome these challenges. Do you think the ethical challenges facing residents today are the same as those that faced residents when the first issue of this book was published?
A: Ethical challenges grow exponentially alongside technological advances. These questions are magnified at both ends of the life spectrum, from the tiniest of preemies to the increasing numbers of elderly people awaiting transplants or other high-tech interventions.
The potential to clone humans or to use stem cells clinically were not on the menu when I trained or when Staying Human first came out in 1989.
“New” infections like SARS have recently challenged us to look at emergency procedures and how decisions around quarantine and access to care get made. We now know that drug companies suppress access to negative studies and that medical schools and research institutes have “complicated” involvements with industry which may impact what students learn. These arrangements are still not fully transparent in most North American medical schools.
What I’ve also noticed is that better methods of testing/investigating patients can take us away from the bedside. Some residents do “lab and scan rounds” rather than visiting the patient’s hospital room. It’s so easy to be seduced by technology.
Q: How do you feel that the deregulation of tuition for medical school in Canada affects graduating medical students going into residency?
A: Debt is one of the biggest stresses facing all new grads in all professions. In medicine it means that residents may choose lucrative specialties rather than areas they love which pay less (like family medicine).
They may over-work in the early years, setting up a pattern of imbalance in their personal lives, which indeed can set them up for burn-out and marital difficulties. High debt can mean that the doctor-patient relationship can become commodified. I hear residents talking about business plans, “clients” and “firing” patients – all lingo borrowed from commerce.
When two-tiered (“private care”) comes to Canada, which I think it unfortunately will, just who is going to keep working in the public system when the private one pays better and interest is accruing on a resident’s student loans? (The average debt now sits at $200,000.)
Q: You write about residents and ways they can help themselves through the difficulties associated with a medical residency. What major changes would you like to see in the medical establishment to make residency less taxing on residents, and what long term effects do you think these changes would have on the practice of medicine in the public domain?
A: In the preface to the book I mention that residents can learn to take better care of themselves but that I didn’t want them to simply accommodate a dysfunctional, outdated training system that often put cost-cutting ahead of resident health and learning and even patient care.
Canadian programs have been at the forefront of regulating the frequency of overnight call and allowing residents to go home post-call. That’s made a big difference.
I’d like to see less emphasis on resident impairment and burn-out and more on resident wellness across the country. We’re fortunate to have an excellent Resident Wellbeing program at the University of Toronto, headed up by Susan Edwards and championed by our dean Catherine Whiteside and deputy dean Sarita Verma. Not every medical school has one and they should. Teach residents how to lead balanced, creative lives early on and this will help them throughout their careers.
I’d like to see more emphasis on the humanities, narrative medicine (which looks at how doctors and patients co-construct stories) and reflective practice in both undergrad and residency curricula. These disciplines emphasize the “art” of medicine and honour the young doctor’s emotional, subjective response to the work they do. Both doctor and patient will be happier for it.
Q: Since the first edition, have you seen any significant changes in medical cultural behavior? Have you seen improvements in the success of residents as a whole?
A: I’ve certainly seen residents stand up for themselves in ways I wouldn’t have dared!
I once had a resident (politely) refuse to work-up a patient because they had already admitted a patient with the same diagnosis and it didn’t fit their learning needs! (I politely asked them to do it anyway.) While I thought “good for you” for speaking your mind, that patient had to be seen and cared for. Older staff get annoyed with residents who see medicine as a job with set hours rather than a vocation and life of service.
There’s a definite generational culture clash occurring in hospitals around the world and either extreme – servitude or selfishness – can be problematic. I think professors need to model both life balance and professional duty to their students and to show the way by example.
I still lean towards the notion of vocation and hope that doesn’t get lost over time.
Q: Have you received feedback from other physicians and residents in the field?
A: I’ve had some wonderful suggestions and feedback via letters, e-mails and personal comments at workshops I’ve given in the U.S. and Canada and they have all found their way into each of the four editions. Women who have had babies during residency have given me helpful, practical tips. International medical graduates have shared their plights with me and shared coping strategies. Techno-geeks have pushed me to incorporate more info on Personal Digital Assistants, websites, online chat/support communities and multi-media learning.
I’ve been really pleased to learn that at least five medical schools in Canada give the book to all of their graduating medical students as an “ounce of prevention.”
Professors are using it to lobby for the creation of wellness programs at their schools. A recurring criticism has been not to get residents to cope too well or to over-function with a potentially deforming experience. I absolutely agree with that and have upped the call to action for systemic change and political engagement in each edition. After all, how we take care of each other as people (who happen to be doctors) will always inform what kind of healers we become.
Dr. Nicole Arbour is a recent graduate from the biochemistry graduate program at the University of Ottawa and currently works as a research scientist with Spartan Bioscience in Ottawa.