Are Puppy Socials the Thing that will save our Residents?

I graduated medical school in 1985 and began my residency in the same year. I endured every third (and sometimes every other) night on call throughout my first two years, awaiting the time that I could reach my third year and do only weekly calls. My daily work schedule was tiring. The average day would last at least 12 hours. In psychiatry, I would work at least 80 hours a week. During my medicine year, I worked well over 100 hours. I remember being constantly exhausted, learning to sleep anywhere I had the chance. I would read when I got home. Days off were catch up time to read the journals. Despite these hours, I do not remember being unhappy. I was living with my future wife and would socialize with friends and fellow residents. There were less hours for this activity, but I would utilize those hours well. Residents would spend time socializing with faculty both in and out of work. We formed a community and were able to support one another.

In 1989, the New York State Legislature enacted New York State Code 405 in response to the death of a patient in a New York City hospital. This changed the number of hours that residents could work in New York and lead to changes nationwide. In 1989, I was a senior resident and a delegate for the Committee of Interns and Residents and was involved in implementing the rules in our hospital. I could not see a downside. There was no possible utility to my peers and I working 110-hour weeks, being chronically exhausted and potentially putting our lives and our patients lives at risk. In addition, I was sure that this would make for happier residents. Who could be happy being chronically sleep deprived?

Thirty years have passed and we no longer expect residents to work those ridiculous hours, but they do not seem happier. We provide meals, and they do not seem happier. We provide protected didactic times and they do not seem happier. We provide puppy socials and ice cream socials, and they do not seem happier. We have spent a great deal of time looking at ways of improving morale and yet rates of depression, burn out and suicide continue to be high.

While Duty hour limits are important, there are other factors that lead to this unhappiness in our residents. To be clear, an 80-hour workweek is still a long week. 24 hours straight is better than 36 hours straight but not by much. Weekends, evenings and holidays away from home and loved ones is never easy. However, we knew the work would be grueling when we decided to go into it. We knew that there would be Christmas mornings that we might be at the hospital. It is part of our occupation, like nurses, police officers and fire departments. Therefore, something more has changed.

I have been working in the field since 1985. I spent my first 20 years working with paper charts. The unit clerk would place lab results in the chart and we knew to go to that section and read the results. The nursing notes were in the same record and often was the first note I read prior to writing my own. I found it much easier, especially since I did not really know anything about computers until the 90’s. Not only was the chart easier, my field was simpler. We knew much less and although that could seem like a problem, as far as reading and keeping up with the literature it was simpler. My didactics were fewer in number, since most of the explosion in the field of psychiatry occurred after I graduated my residency. We had medication but our understanding was nowhere near, what it is today. We provided therapy, but the pressure for manualized and evidenced based therapies was not there. When I graduated I did not require the Boards to practice, but took them since it was expected when graduating a medical school program. I was able to keep up with my field by reading two journals, The American Journal of Psychiatry and The Journal of Clinical Psychiatry. I was also able to keep my skills in internal medicine fresh and added the Annals of Internal Medicine. There were regulatory agencies but they did not seem to have as profound of an effect on my daily practice. The only constant torture was the writing and reviewing of the treatment plans, which to this day confuse me.

The field slowly changed around me, and became more connected with regulations, “best practices”, algorithms, manualized care, quality improvement, risk management, managed care, population health etc. The knowledge base also exploded. Neuroscience became dominant, and medications were appearing at a rapid rate. At first, I was able to keep up with the changes, but eventually felt buffeted by the waves of change.

So how does all this affect physicians and trainee wellbeing? It creates a complex system of care and a complex system of learning that now takes a great deal of time and energy to navigate. The influx of information alone threatens to drown the practitioner and student alike. As our knowledge base increases, the quality of the trainee improves. I would often tell my residents that I would not have given myself a position if I had applied today and that is true. Residents are an accomplished group of individuals, more accomplished than I am now with 30 years of practice. They have spent years preparing for this moment. Getting into the right medical school, then the right residency, then the right fellowship and then the right first job. There is more competition than ever before. Once in however, they face problems that plague our field. These problems create an environment that diminishes the spirit of these bright people. They enter data into fields on the screen in front of them day and night. They do not make eye contact with others in the various nursing stations. Patients “interfere” with their getting their work done which now has to be done in a certain period so that they do not violate duty hours. They dutifully complete their tasks but there is little time to find joy in their work. They learn to complete scales that will lower their medico-legal risks. They learn to argue with pharmacies in order to try a new medication.

Their didactics are crowded with all the information that has developed in the field and it is a voluminous amount of material. Information keeps piling up but of interest is the lack of real clinical utility. The resident must wade through tons of studies and rarely finds one that actually informs their clinical practice.

So how do we improve overall morale and wellbeing? We become truly transparent. We model professionalism in the face of the ever-changing landscape of medicine. We remain focused on what our mission is, which the care of the patient is.

To be transparent is number one on my list. We begin by being honest with our trainees. When they apply to our program, we tell them the full story, good and bad. We stop hiding behind platitudes of duty hours, and honestly tell them that residency is hard work. We do our best to protect them from the overwhelming needs of the Department, but we cannot always be successful. When they become overwhelmed, we listen and we support. Moreover, we should not threaten.

My favorite part of psychiatry residency is when they enter into the third year of training and they are exclusively outpatient psychiatrists. Despite the decrease in hours, they never seem to be able to handle the load. They keep pointing to all the extra “social work” they are required to do. One day I looked at the form they were complaining about filling out and I noticed it said “Physician Report and Signature”. I asked how this is a social work duty when it clearly states physician on the form. It was as if they never saw it before. I approach the issue directly. They will be filling out forms. They will be faxing things. They will be taking commands from non-MD leadership. Regulatory agencies will place demands on their work and scrutinize performance. In addition, they will be pushed to see patients. Residents bring in a good amount of income without the direct cost. Once I started speaking candidly to my trainees, the majority dealt with things better. They are highly intelligent. They can handle the “truth”.

Professionalism in the face of the present landscape is difficult, but becomes essential during this time. I remember the thrill of receiving my scrubs and beeper on July 1, 1985. I was finally a doctor and 35 years later, remain fascinated by my work. I feel blessed that I have a job that pay well and allows me to be of service to my fellow man. I have been blessed to be able to teach young people about the field. The “business” of medicine might have changed in the past 35 years, but the physician’s mission has not. The essence of being professional understands that in the end, the doctor-patient relationship remains the true mission of our field. We should share this excitement and dare I say, joy , with our trainees.

Finally, listen, support and do not threaten. We might not like what the trainee says about us, our peers, our department, but we need to listen. They often come with a fresh set of eyes that might be of service to the department. Listen and think. If things can be improved, try. If things cannot be, support the trainee and their feelings of frustration. Never, never, never (I can write this multiple times) make the trainee feel that they are in jeopardy of losing their career because they express dissatisfaction. Allow them to feel that your training office is a safe space. One of the things I have found in multiple training programs is the fact that residents do not feel safe to express things. I have often wondered why, but I have heard faculty express threatening statements. In truth, short of gross negligence, and gross boundary violations, firing a resident is actually quite difficult. In short, I am not going to go through all that work just because someone hurt my feelings.

In the end, we need to express to our trainees that our goal is to graduate them and help them become clinicians that we could trust with our friends and family. I enjoy picking up the telephone and referring a patient to one of my trainees. It is the ultimate reward to have assisted someone in the journey to become a caring and competent clinician. We should probably start on July 1 with the statement “we want you to become clinicians that we can trust, and that we will be proud to call “colleague”. In the end, that is the true mission.