Navigating Challenges In Residency Programs

These third-year residents discuss institutional support in their programs, how to handle on-call responsibilities and working with fellow residents who may be underperforming.

Q:

How would you relate the institutional support that you have received from your program? Is taking personal and vacation days viewed negatively? Are you 100 percent clear on your benefits? How do benefits compare to those of your classmates?

A:

Dalton Ryba, DPM, notes the residency programs and their respective members at the John Peter Smith Hospital in Fort Worth, Texas receive adequate backing. As he says, this includes having strategic plans in place for growth in medical education, innovation, support in research and development, and technological advancement.

Wesley Jackson, DPM, says Main Line Health is very supportive of his residency program and its residents in several ways. Residents have a residency coordinator that he and fellow residents can approach at any time with any questions or concerns. Dr. Jackson also has the ability to go to any conference and be reimbursed for the conference/travel cost. He adds that the reimbursement cap increases if attendees are presenting an article or poster at a conference.

Tenaya West, DPM, says her residency program has “excellent institutional support.” She notes Kaiser Permanente provides resources for residents “not only to excel within their specialty but to thrive outside the hospital as well.” She cites examples such as yearly professional development courses, a research department dedicated to helping residents produce original research and funding for courses and conferences. Dr. West says wellness support includes a monthly budget for a gym membership, sponsored residency outings to local events and interdepartmental sports games.

“It is easy to work hard and put in long hours at the hospital when you feel supported and appreciated by not only your program, but the institution as well,” maintains Dr. West.

All three panelists note they get an explanation of their benefits at the beginning of the year. Dr. Ryba’s program clearly spells out the guidelines for resident time off from work, including sick days, personal days and paid vacation. He notes the allotted time off increases with each post-graduate year and residents in his program have these days available to them if needed. However, Dr. Ryba notes taking time off is not always so easy. He says the environment and workload in the program are not “conducive to routine time off, particularly for multiple days at a time.

“(Being in) a program that fosters resident autonomy, we rely heavily on one another for the completion of the daily tasks,” says Dr. Ryba. “At times, performing these tasks efficiently is not possible without every member of the team being held accountable. Ultimately though, each of us understands the importance of personal time away from work. … As long as time off is planned in advance, it is never looked upon as negative.”

Dr. West says her program never views personal and vacation days as negative. Her attendings and co-residents always encourage her to take days off to recharge. Dr. Jackson’s program also encourages residents to take vacation days. The program specifically stresses to residents to take at least a week of mandatory vacation. “We work extremely hard as residents and vacation is needed from time to time,” says Dr. Jackson.

In regard to physician time off, Dr. Ryba says the residency program reviews residents’ benefits at the beginning of each year. Moreover, he notes there are “constant reminders through multiple lines of communication” to residents that the program has a support staff for any questions or concerns regarding resident benefits. Dr. Jackson notes human resources is always available by phone or email for any new questions/concerns about benefits. He calls his program’s salary and benefits package at Main Line Health “well above the neighboring programs’ salaries and benefits.”

“We are fortunate to have a strong benefits package at our institution (the aforementioned John Peter Smith Hospital) and I believe the benefits rank highly in comparison to other programs across the country,” says Dr. Ryba. 

Q: 

How has your program handled on-call responsibilities for residents? Did you ever feel like you were being asked to handle too much in terms of on-call hours? Can you recall any specific examples? What advice would you give to incoming residents about how to handle being on call? What advice would you suggest to residency directors about divvying up the on-call work?

A:

Dr. Jackson’s on-call responsibilities are part of a two-resident call system in which there is always a primary call resident and backup call senior resident working. As he explains, the primary call resident is responsible for all consults, pages, etc., for the designated call timeframe. If those responsibilities become overwhelming or physically impossible to do at a specific time, he says the backup call resident is on site to alleviate this burden.

As an example of the system’s efficiency, Dr. Jackson considers when a primary call person has two trauma ED consults at the same time in different hospitals. In that situation, one resident is providing care to an ankle fracture at Hospital A while the backup call resident is providing the same care at Hospital B. As weekend rounding can become overwhelming, especially if compounded with weekend OR cases and/or ED pages at the same time, he says the two residents can divide up the responsibilities accordingly.

In Dr. West’s program, all residents evenly share on-call responsibilities. She has had the challenge of extremely busy call weeks “but never felt it was something I couldn’t handle.” Dr. West cites the support of co-residents and attendings, especially on the tough weeks.

“We are constantly looking out for each other and making sure no resident is tasked with something that is too much for her or him to safely handle,” says Dr. West.

Dr. Ryba’s on-call duties are consistent month to month and duties decrease in duration with each post-graduate year. The chief resident sets the call schedule and the program director approves it. He notes the intern on service typically takes eight to 10 call days per month, including two of the four weekends. Dr. Ryba says second-year residents then each take an additional weekend and two to three weekdays. The chief resident on service (six months/year) takes two or three call days per month. Dr. Ryba says the orthopedic third-year residents on the foot and ankle rotation take three to five days per month. He says the off service (six months/year) third-year resident has no call days.

“Being on call is part of the learning experience of residency and the gravity of this should be understood prior to commencement,” emphasizes Dr. Ryba.

Despite many examples in which he felt overwhelmed, Dr. Ryba never experienced any specific instances when he felt he was being asked to take on more than he and his support staff could handle.

Dr. Ryba advises incoming residents to first inquire about resident expectations at prospective programs prior to application. Second, he says residents should decide on a program based on what they feel they are capable of handling/willing to endure with the understanding that competency and work ethic are interrelated.

Dr. Jackson says residents should be familiar with the patient list on a given day/rounds at the hospital to answer any floor questions quickly and efficiently. Lastly, he suggests residents do any rounding or consults as quickly as possible to allow them to rest or decompress before any possible surgical emergency page comes in, or a barrage of pages come in due to different issues from the floor, post-anesthesia care unit or emergency departments.

Dr. West advises incoming residents to learn early on how to be efficient with their work so they will be better able to enjoy the process. In addition, Dr. West advises residents to take care of themselves so they don’t burn out. Dr. Jackson would advise incoming residents to always get a great night of sleep the night prior to the call day or night.

Dr. West encourages residency directors to include their residents in dividing call duties and to have the residents take ownership of the schedule. As one of the chiefs within her program, Dr. West works with her co-residents to make a call schedule they all feel comfortable implementing.

Dr. Ryba would recommend that program directors construct a call schedule specific to the program’s demand, a schedule that places the resident in a position to learn and grow through on call opportunities. He warns that allocating call days based on punishment or preeminence “does not promote motivated attitudes.”

Dr. Jackson would advise residency directors to make sure they have a back-up call resident in place to help alleviate the workload for any primary call resident who is overwhelmed with work on a given day/night.

Q:

Do you feel you constantly have to support and cover for other residents? Can you talk to your program director about underperforming junior residents? Do directors take actions on your suggestions?

A:

Dr. West’s program has a culture in which residents all constantly support each other, for which she is “extremely grateful.” While residents have the ability to work independently, she notes they function much better as a team and this makes the residency experience both more educational and more enjoyable. Along the same lines, Dr. West notes the close working relationships allow residents to manage any issues that may come up between themselves. However, she says the attendings are always available to discuss how residents can maximize the potential of their co-residents. She notes attendings are “highly responsive” to residents’ suggestions, saying residents and attendings work together to take action.

Dr. Ryba notes his program promotes and embraces autonomy through its training methods, but always in parallel with collaboration. The program’s residents support one another, resident to resident, and resident to attending, and he notes the program would not function without that mindset and understanding. Accordingly, Dr. Ryba says accountability and coachability are at the forefront of his program’s values with each resident understanding that underperformance first meets support and then meets action. Dr. Ryba says he fellow residents and attendings appreciate the idea of growth through adaptation. If something is not working, he and his colleagues isolate the problem and come up with a solution.

“Change occurs regardless of position and it is this belief that makes a successful and pleasant working environment,” explains Dr. Ryba. “A successful residency program, including residents and attending staff, is built very much on the principles of team.”     

As a senior resident, Dr. Jackson “wouldn’t be doing my job if I wasn’t constantly available to support my younger residents.” He stresses that experienced residents must help teach and mentor new residents, and make them the best residents they can be.

However, Dr. Jackson has never felt the need to “cover” for any resident. He cites his program’s expertise with teaching new residents within the first six weeks on the job how the logistics of the job work. As for clinical diagnosis and treatment plans, his program always has senior residents and attendings available. Residents can talk directly with the director if they feel like there is any issue with a resident, performance-based or not. Dr. Jackson says the director takes residents’ suggestions seriously and will handle any issue accordingly and in a timely manner.

Dr. West says residents came up with the core principles of their program: commitment, passion, balance, respect and family. She says residents strive to reflect those values in their relationships with each other, staff and attendings.

“By doing so, we are able to maintain a culture in which we inspire each other to be better and nobody feels that they have an unfair share of the workload,” notes Dr. West.

Dr. Jackson is a Chief Resident in the Podiatric Medicine and Surgery Program at Main Line Health in Bryn Mawr, PA.

Dr. Ryba is a Chief Resident in the Department of Orthopedics at John Peter Smith Hospital in Fort Worth, Texas.

Dr. West is a Chief Resident at the Kaiser San Francisco Bay Area Foot and Ankle Residency Program.

Dr. Bernstein is the Director of the Podiatric Residency Program at Bryn Mawr Hospital in Wayne, Pa. He is a Fellow of the American College of Foot and Ankle Surgeons.