Residency: Thriving Through Challenges

Residency can represent an exciting gateway to achievement through hands-on learning and professional development. In pursuit of professional growth, there are many challenges encountered during residency training. We all are familiar with the obvious challenges of residency in developing competent surgical skills, performing research, developing time management, and learning from off-service rotations to have a well-rounded medical and surgical education. However, there are other non-medical skills that one must develop to successfully navigate residency training today. These non-cognitive skill sets include adapting to the dynamic work environment with co-residents and faculty and establishing good, sound clinical and surgical judgement. Recognizing these traits will allow each resident to maximize learning during residency and create a collegial atmosphere for the resident and faculty.

Bridging The Gap

In our observation, most current residents being from the Millennial and Generation Z (Gen Z) groups (see figure above) and most established attendings being from an earlier generation, Baby Boomer or Generation X (Gen X), there can be a clash in teaching and learning styles, socialization, and meeting expectations. Often, negative traits ascribed to Millennials and Gen Z include descriptors such as “lazy” and “having a sense of entitlement.” In contrast, perceptions of preceding generations may include being “rigid” and “uncompromising.”

Differences can become detrimental if we fail to understand that each generation has their own perspective and that each side must learn to compromise to create an environment conducive to learning and teaching. For example, we have observed attendings from the Gen X era or earlier state that when they were residents, they were taught to do solely as their attendings instructed with staunch obedience and without questioning the rationale. In today’s training climate, this methodology is not effective. Understanding the rationale behind why things are done in a certain manner is more important than how to do it. With evolving medical/surgical options and access to information instantaneously on smart devices, today’s residents are exposed to different perspectives previously not as readily available.

Attendings must be open to explaining their reasoning for that teaching moment to be effective. In our experience, residents are otherwise less likely to take instruction openly when there is conflicting information. Ultimately, having sound, well-thought-out plans will have a more lasting impact in shaping clinical decision-making. Developing a clinical rationale allows trainees to understand conceptually, which is far more efficient in learning the art of medicine. Preceding generations may misinterpret this need for a why answer to questions as a challenge to authority that can lead to rifts between attendings and curious residents. An open dialogue between attendings and residents can be beneficial, so both sides can explain and understand their point of view and respective intentions. Furthermore, building interpersonal relationships between attendings and residents can foster a superior learning environment where respect and open communication can both flourish with mutual respect, rather than a top-down approach that may lead to frustration and resentment.

Adaptability

Transition into residency from podiatric medical school requires developing time management skills and learning how to be adaptable. Residents are expected to learn the preferences and personalities of each attending. It can be daunting to meet an attending for the first time preoperatively and be expected to know all their individual preferences. The variations can include when to contact the attending preoperatively to discuss the case, or whether or not to use a tourniquet before performing an infected case. When trying to earn the trust of the attending, the resident must be aware of these details to earn the privilege of being the primary assistant or have an opportunity to perform critical parts of the case. Some attendings will quickly take the blade away if the resident does not meet some of these expectations. On the other hand, some attendings are more open to listening to resident rationale, having intraoperative discussions and incorporating that into the surgery. In the end, the onus is on the resident to keep track of attending preferences and learning to be adaptable. Although challenging, the hidden advantage of having on opportunity to learn from many attendings is having different experiences from which each resident can pick and choose which aspects they want to incorporate into their surgical style.

Working in a hierarchy with co-residents also requires compromise and adaptability. Much of learning during residency comes from working with co-residents. For example, senior residents can take junior residents under their guidance through surgery for the first time. In our experience, residency programs require all residents to work closely and collaboratively for long hours, often under strenuous circumstances. Naturally, conflicts can arise when working in such proximity and frequency. Furthermore, co-workers with differing values, temperaments, and expectations will test their patience and friendships. Just as there is a dynamic between attending and resident, there exists one between residents. Each resident brings different opinions, experiences, and points of view that warrant value and consideration. Pausing to understand another's reasoning and communication styles can be challenging, but rewarding through learning something new. By adapting to resident personalities, the residency environment can foster a respectful, collegial, and safe space for learning that has opportunity for open communication and conflict resolution. A well-functioning residency program must have adaptable faculty and residents for good camaraderie.

Developing Confidence

At the end of residency training, the training wheels drop and graduates are expected to be independently thinking physicians with the acumen to clinically and surgically manage patients. Aside from gaining basic knowledge and surgical skills, the acquisition of self-confidence is typically not a part of the training curriculum. At our program, we encourage residents to independently develop differential diagnoses and formulate a treatment plan from the first day of training. Rather than relying on a superficial understanding of procedures, we push residents to justify surgical plans from both biomechanical and evidence-based perspectives. Although stumbling through the dialogue of reasoning can be uncomfortable at times, it serves a greater purpose in the development of a resident’s clinical judgment. We expect our residents to be inquisitive regarding an attending physician’s methodology so that when we discuss them in our weekly academic sessions, everyone can share in that insight. This process aids in developing a resident’s critical thinking skills rather than just doing things blindly. Residency only provides three years of training to convert a medical student into a competent surgeon. This transition takes time to develop and should begin as soon as possible. Through repetition and practice, we feel residents that take this challenge seriously gain confidence and intuition that they will take with them into their professional career after residency.

Navigating the challenges of residency can lead to residents learning to work with varying individuals with differing backgrounds, adapting to different situations, and developing confidence in their clinical and surgical skills. Taking advantage of these opportunities should be embraced and maximized during residency training. By understanding generational differences between residents and faculty, the learning environment can be harmonious and less frustrating. Learning to adapt helps a resident develop into a dynamic physician who can handle challenging circumstances with patients and staff. Encouraging residents to develop clinical and surgical plans on their own and having an open dialogue regarding such decisions allows residents to develop critical thinking skills and self-confidence. These experiences will ultimately help shape each practitioner and help them become contributing members of our profession.

Dr. Husain is the Residency Director of the McLaren Oakland Hospital Podiatric Surgery and Medicine Residency Program in Pontiac, MI. He is a Fellow of the American College of Foot and Ankle Surgeons and a Fellow of the American Society of Podiatric Surgeons. Dr. Husain is also the President-Elect of the Michigan Podiatric Medical Association and Chairman of the Michigan Podiatric Residency Consortium.

Dr. Srivastava is a third-year podiatric resident at McLaren Oakland Hospital in Pontiac, MI.

References

1. Envirox. Hiring the future: understanding generational differences. Available at: https://www.enviroxclean.com/blog/hiring-the-future-understanding-generational-differences. Published December 13, 2018.  Accessed September 28, 2021.