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medical center, emphasizing housestaff autonomy and self- reliance. PARTICIPANTS: A cohort of 18 of 21 medical residents at. Bellevue Hospital Center during ...
Learners as Teachers: The Conflicting Roles of Medical Residents Michael J. Yedidia, PhD, Mark D. Schwartz, MD, Colleen Hirschkorn, MPA, Mack Lipkin, Jr., MD

OBJECT/VE." To explore the impact o f internal m e d i c i n e residents' roles as learners, t e a c h e r s , and p h y s i c i a n s o n their performance in t e a c h i n g and s u p e r v i s i n g interns; to g e n e r a t e insights for e d u c a t i o n a l p o l i c y and r e s e a r c h . D E S I G N : Qualitative analysis o f in-depth, s e m i s t r u c t u r e d , re-

corded interviews with a c o h o r t o f s e c o n d - p o s t g r a d u a t e - y e a r (PGY-2) residents. Q u e s t i o n s elicited their a c c o u n t s o f differences in the learning p r o c e s s b e t w e e n the first and s e c o n d residency years, their r e s p o n s e s to s i t u a t i o n s in w h i c h t h e y lacked s u f f i c i e n t clinical k n o w l e d g e , their v i e w s o f their s u pervisory relationship w i t h interns, a n d their a s s e s s m e n t s o f changes in their role in patient care s i n c e their i n t e r n s h i p s . Transcripts were i n d e p e n d e n t l y a n a l y z e d by the interdisciplinary team o f authors. S E T T I N G : New York U n i v e r s i t y / B e l l e v u e Hospital Center's

internal m e d i c i n e r e s i d e n c y (New York City), a h i g h l y c o m petitive program in a major public hospital and a u n i v e r s i t y medical center, e m p h a s i z i n g h o u s e s t a f f a u t o n o m y and selfreliance. P A R T I C I P A N T S : A c o h o r t o f 18 o f 2 1 m e d i c a l r e s i d e n t s at

Bellevue Hospital Center during the last rotation o f PGY-2. I n t e n s e c o n f l i c t s c o n f o u n d residents' roles as teachers. T h e s e c o n f l i c t s fall into three categories: 1) as learners, residents' o w n n e e d s f r e q u e n t l y c o i n c i d e w i t h t h o s e of interns in w a y s that m a y u n d e r m i n e their t e a c h l n g - - t h e y are e x p e c t e d to nurture o t h e r s d e s p i t e their o w n c o n s i d e r a b l e needs for e m o t i o n a l support, t e a c h material that t h e y barely grasp, and exert authority w h i l e f e e l i n g ignorant; 2) as t e a m leaders, residents m u s t e n s u r e that i n t e r n s get the hospital's work done, s o m e t i m e s at the e x p e n s e o f t e a c h i n g t h e m ; and 3) as clinicians, residents' first priority is to address the reedical n e e d s o f p a t i e n t s - - t h e learning n e e d s o f interns are s e c -

RESULTS:

ondary. C O N C L U S I O N : S e c o n d - y e a r internal m e d i c i n e r e s i d e n t s ex-

perience c o n f l i c t s i n h e r e n t in their s i m u l t a n e o u s c o m m i t ment to learning, t e a c h i n g , a n d service that m a y u n d e r m i n e both their e f f e c t i v e n e s s in s u p e r v i s i n g i n t e r n s and their o w n professional d e v e l o p m e n t . Potential r e m e d i e s are to restructure r e s i d e n c y programs so as to equip r e s i d e n t s w i t h training and support for their role as t e a c h e r s , r e d u c e the t e n s i o n between training and service by delegating tasks to n o n p h y sician p e r s o n n e l , and provide graded r e s p o n s i b i l i t y to h o u s e staff as p h y s i c i a n s and t e a c h e r s . KEY WORDS: graduate medical e d u c a t i o n ; r e s i d e n c y training; residents' roles; p h y s i c i a n soclaHzat/on; internal medicine; qualitative c o h o r t study. J GEN INTERN MED 1 9 9 5 ; 1 0 : 6 1 5 - - 6 2 3 .

esidency t r a i n i n g i n m e d i c i n e i m p o s e s m u l t i p l e a n d conflicting roles o n t r a i n e e s : at once, they are learners, teachers, a n d p h y s i c i a n s . T h e complexity of the m u l tiple roles a s s u m e d by r e s i d e n t s is u n i q u e a m o n g the professions a n d deserves a t t e n t i o n to its c o n s e q u e n c e s . While experiential l e a r n i n g is available to law s t u d e n t s , playing the role of provider is n o t c e n t r a l a n d u n i v e r s a l to legal t r a i n i n g as it is i n m e d i c i n e . 1-a D i s t i n c t i v e to medical t r a i n i n g , as well, is r e s i d e n t s ' d u a l role as learners a n d teachers. R e s i d e n t s devote as m u c h as 2 0 - 2 5 % of their work time to t e a c h i n g activities a n d have m a j o r responsibility for the t r a i n i n g of i n t e r n s a n d medical s t u d e n t s . 4-" This article reports the s e c o n d year of a three-year qualitative s t u d y of a cohort of i n t e r n a l m e d i c i n e residents. ~o It e x a m i n e s the roles a s s u m e d b y r e s i d e n t s a n d assesses the c o n s e q u e n c e s for t h e i r effectiveness i n teaching a n d s u p e r v i s i n g i n t e r n s . T h e t h e m e s d i s c u s s e d here emerged from a n a l y s i s of i n - d e p t h interviews w i t h medical r e s i d e n t s r e g a r d i n g their roles as learners, teachers, a n d p h y s i c i a n s . " I n t e r n " refers to a p h y s i c i a n in the first p o s t g r a d u a t e year (PGY-1) a n d " r e s i d e n t " here refers to a p h y s i c i a n i n PGY-2, u n l e s s otherwise

R

noted.

METHODS The cohort of PGY-2 r e s i d e n t s o n r o t a t i o n o n the i n t e r n a l m e d i c i n e w a r d s i n J u n e 1992 at Bellevue Hospital Center was s t u d i e d . E i g h t e e n of 21 r e s i d e n t s were interviewed. Two of the three who did n o t keep t h e i r a p p o i n t m e n t s h a d b e e n interviewed as p a r t of the i n i t i a l s t u d y of i n t e r n s ; they did n o t differ i n a n y s y s t e m a t i c way from their fellow i n t e r n s i n t h e i r a s s e s s m e n t s of the t r a i n i n g experience.

Received f r o m the H e a l t h R e s e a r c h Program, Robert F. W a g n e r G r a d u a t e School of Public Service, N e w York University (MJY, CH). a n d the Division o f Primary Care, D e p a r t m e n t o f Medicine, N e w York University M e d i c a l Center (MDS, ML), N e w York, N e w York. Supported by a g r a n t f r o m the Z l i n k o f f F o u n d a t i o n f o r Medical R e s e a r c h a n d E d u c a t i o n , Providence, R h o d e Island. Address correspondence a n d reprint requests to Dr. Y e d i d i a : Health R e s e a r c h Program, Robert F. W a g n e r G r a d u a t e School of Public Service, N e w York University, 7 E a s t 12th S t r e e t - Eighth Floor, N e w York, N Y 10003.

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Y e d i d i a et al,. Conflicting Roles of R e s i d e n t s

Residents s p e n d 80% of t h e i r time at Bellevue Hospital Center, the major t e a c h i n g h o s p i t a l for New York University School of Medicine. T h i s is a 1,280-bed public hospital t h a t serves the p r i m a r y t h r o u g h tertiary care needs of the i n d i g e n t p o p u l a t i o n of lower M a n h a t t a n . Residents s p e n d one a n d o n e - h a l f m o n t h s per year at Tisch University Hospital, a 720-bed h o s p i t a l s e r v i n g the greater New York m e t r o p o l i t a n area, i n c l u d i n g a large percentage of private, tertiary care p a t i e n t s . T h i s highly competitive p r o g r a m e m p h a s i z e s h o u s e s t a f f a u t o n o m y a n d self-reliance a n d the i m p o r t a n c e of t a k i n g initiative in caring for p a t i e n t s . In a d d i t i o n , it r e q u i r e s h o u s e s t a f f to do moderate a m o u n t s of " s c u t w o r k " (tasks t h a t could be h a n d l e d by clerical or t e c h n i c a l staff); s u c h n o n c l i n ical work a m o u n t s to 14% of r e s i d e n t work, w h e r e a s dedicated e d u c a t i o n time a c c o u n t s for 20% .9 Development of the o p e n - e n d e d q u e s t i o n n a i r e for the s t u d y was i n f o r m e d by medical e d u c a t o r s , researchers, a n d a focus g r o u p interview w i t h r e s i d e n t s who were not part of this study. In-depth, s e m i s t r u c t u r e d interviews, averaging 50 m i n u t e s , were c o n d u c t e d at Bellevue (by CH). The q u e s t i o n s focused o n r e s i d e n t s ' p e r c e p t i o n s of differences i n the l e a r n i n g process b e t w e e n the first a n d second residency years, t h e i r r e s p o n s e s to s i t u a tions in w h i c h they did n o t have s u f f i c i e n t knowledge to make a clinical d e c i s i o n or to a n s w e r a n i n t e r n ' s question, their views o n the e l e m e n t s of a good s u p e r v i s o r y r e l a t i o n s h i p with i n t e r n s , t h e i r a s s e s s m e n t of c h a n g e s in their role in p a t i e n t care s i n c e t h e i r i n t e r n s h i p year, a n d their comfort w i t h d e l e g a t i n g p a t i e n t care r e s p o n sibilities to other r e s i d e n t s a n d w i t h s i g n i n g o u t at the end of the day. Table 1 s h o w s a topic list a n d s a m p l e questions. The interviews were a u d i o t a p e d a n d t r a n s c r i b e d for analysis. The i n v e s t i g a t o r s - - a n i n t e r d i s c i p l i n a r y t e a m with expertise i n clinical a n d a c a d e m i c m e d i c i n e (ML, MDS, MJY), sociology (MJY), n u r s i n g (CH), a n d h e a l t h care m a n a g e m e n t ( C H ) - - i n d e p e n d e n t l y read the t r a n scripts, c o d i n g v e r b a t i m p a s s a g e s by t h e m e a n d exami n i n g the r e s u l t i n g categories to identify c o m m o n concerns a n d r e c u r r e n t issues. They reached c o n s e n s u s a b o u t the t h e m e s reported here. C r i t i q u e of a draft of the research report was solicited from key faculty i n m e d i c i n e . As d i s c u s s e d i n the i n i t i a l report from this study, 1o this inductive q u a l i t a t i v e a p p r o a c h to a n a l y s i s is particularly s u i t e d to exploratory research. I I T h i s process relies o n repeated review of the t r a n s c r i p t s by m e m b e r s of the research t e a m a n d verification of the a c c u r a c y a n d cogency of t h e i r i n t e r p r e t a t i o n s by h o u s e s t a f f a n d faculty. ~2Typical p a s s a g e s selected from the t r a n s c r i p t s are quoted v e r b a t i m (in small type a n d i n d e n t e d ) - - a l l o w i n g residents to speak for themselves. Where a p p r o p r i a t e , the frequencies with w h i c h p a r t i c u l a r views were expressed are noted. However, the q u e s t i o n s did n o t force the r e s p o n d e n t s to c o m m e n t o n prespecified p o i n t s of view. The t h e m e s reported here e m e r g e d afterward from a systematic a n a l y s i s of v o l u n t e e r e d c o m m e n t s . Con-

sequently, the f r e q u e n c i e s r e p r e s e n t conservative estimates of the prevalence of specific beliefs. Excerpts from the t r a n s c r i b e d interviews, r e p r e s e n t i n g the e m e r g i n g themes, were s h a r e d with a g r o u p of 20 i n t e r n s a n d residents at Bellevue who were n o t part of the s t u d y cohort: they c o n f i r m e d the i m p o r t a n c e of the i s s u e s discussed in this article.

RESULTS The analysis disclosed a series of forces t h a t a p p e a r to c o m p r o m i s e r e s i d e n t s ' p e r f o r m a n c e i n t e a c h i n g a n d s u p e r v i s i n g i n t e r n s . T h e s e c o n f o u n d i n g forces e m a n a t e from their multiple roles as learners, as t e a m leaders, a n d as clinicians. The major t h e m e s t h a t emerged are: 1) as learners, r e s i d e n t s ' own n e e d s frequently coincide with those of i n t e r n s i n ways that m a y u n d e r m i n e t h e i r teaching; 2) in t h e i r p o s i t i o n i n the workforce, r e s i d e n t s m u s t e n s u r e t h a t i n t e r n s do the h o s p i t a l ' s work, even at the expense of t e a c h i n g t h e m ; a n d 3) as c l i n i c i a n s , residents" first priority is a d d r e s s i n g the medical n e e d s of patients, n o t the l e a r n i n g n e e d s of i n t e r n s .

Learners as Teachers Asked how they conceived of t h e i r t e a c h i n g role w i t h respect to i n t e r n s , the r e s i d e n t s e m p h a s i z e d three m a j o r responsibilities: fostering a positive l e a r n i n g experience, creating a s u p p o r t i v e e n v i r o n m e n t , a n d s u p e r v i s i n g delivery of p a t i e n t care. They are expected to teach m a t e r i a l that they have barely or newly grasped: they are relied on to n u r t u r e others at a p o i n t i n t r a i n i n g w h e n t h e i r own needs for e m o t i o n a l s u p p o r t are considerable; a n d they are r e q u i r e d to exert a u t h o r i t y while b e c o m i n g increasingly aware of t h e i r own i g n o r a n c e .

Creating a Supportive Learning Environment: Nurturing [While Seeking Support] The process of teaching, itself, often c o n t r i b u t e d to u n d e r m i n i n g the r e s i d e n t s ' self-esteem. T h e r e s i d e n t s characterized t h e i r t e a c h i n g m a i n l y as r e s p o n d i n g to i n t e r n s ' q u e s t i o n s a n d h a d mixed feelings a b o u t this task. On the positive side, several r e s i d e n t s v o l u n t e e r e d that their own l e a r n i n g experiences were c o n s i d e r a b l y enhanced: You learn by teaching this year, which is true to a greater extent than it was last year. Good interns teach their medical students as well, but you're [PGY-2s] teaching more people, you're asked more difficult questions, and so that forces you on your own to go seek out some answers that you may not find. On the negative side, the i n t e r n s , h a v i n g a b u n d a n t need for s u p e r v i s i o n , were always c o n f r o n t i n g r e s i d e n t s with the limits of t h e i r knowledge. A n d the r e s i d e n t s , already t r o u b l e d by the i n c r e a s i n g l y difficult l e a r n i n g s i t u a t i o n s they are r e q u i r e d to m a s t e r , expected to serve

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Table 1 Questionnaire Topics and Examples of Items Topic Role as a Learner

Sample Questions How does the process of learning this year, as a second-year resident, differ from last year? If you are confronted with a clinical issue a n d do not have adequate knowledge for m a k i n g a decision, how will you learn w h a t you need to know? How do your n e e d s for knowledge differ as a second-year r e s i d e n t c o m p a r e d to as a n i n t e r n ?

Role as a Teacher

What are the elements of a good supervisory relationship with an i n t e r n ? What have b e e n s o m e of the p r o b l e m s ? If a n i n t e r n asks you a q u e s t i o n a n d you do not know the answer, w h a t will you do? T h i n k i n g back to July or August, h a s your a p p r o a c h to this situation c h a n g e d over the course of the year? How m u c h of a free h a n d do you permit i n t e r n s to exercise in the care of their p a t i e n t s ? How do you decide w h e n a n intern is in over his or her h e a d ?

Role as a Doctor

How would you characterize your role in p a t i e n t care d u r i n g the p a s t year? How does this compare to your i n t e r n s h i p year? Who do the p a t i e n t s covered by your team belong to, whose p a t i e n t s are they? Have your feelings a b o u t this c h a n g e d since your i n t e r n s h i p year? Do you feel comfortable delegating patient care responsibilities to o t h e r r e s i d e n t s ? Why or why n o t ?

a s a u t h o r i t a t i v e role m o d e l s . F o r s e v e r a l r e s i d e n t s , t h e p r o s p e c t of n o t k n o w i n g t h e a n s w e r to a n i n t e r n ' s q u e s tion was unnerving: I think overall my one struggle all the time is that I feel I don't know enough and I hope that's c o m m o n to everybody b u t I think that's been the biggest problem. And so w h e n I m confronted with a q u e s t i o n t h a t I feel I should know, my initial reaction is to p u n i s h myself or feel 'You don't know this. I can't believe you don't know this a n d you're already a secondyear resident and you're soon to be a third-year r e s i d e n t and you don't know the a n s w e r to this question."

personal health as well as m e n t a l . . , health. After that. w h i c h that gets you past the first few m o n t h s w h e n they s t a r t getting efficient, and after that it's really helping to make t h i n g s fun by teaching about the cases a n d make t h e m really p r e s e n t the cases to you. As a p p r e n t i c e s , i n a d d i t i o n to b e i n g t a u g h t b y example, interns learn by acknowledging their mistakes, discussing them

with their supervisors,

and

asking

q u e s t i o n s . I n t e r n s m u s t feel s a f e i n r e v e a l i n g t h e i r ign o r a n c e a n d a s k i n g for h e l p w h e n n e e d e d . S e v e r a l r e s idents acknowledged their responsibility in creating a safe l e a r n i n g e n v i r o n m e n t :

Another resident, acknowledging such disappointment, reported: l j u s t felt like, 'Why am I even h e r e ? What am I doing?" Existing side-by-side with such profound self-doubts among residents about their own knowledge was their nearly unanimous

belief in nurturing

recently completed internship,

interns. Having

t h e s e PGY-2 r e s i d e n t s

1 think fostering a relationship t h a t will enable t h e m to ask questions without being e m b a r r a s s e d a b o u t w h a t they do or don't know its important] . . . . I t h i n k t h a t ' s very i m p o r t a n t because there's so m u c h t h a t you don't know and there's some things that you feel really s t u p i d a n d you are embarrassed to ask . . . . {You] should know this kind of thing. But I think it's i m p o r t a n t to be able to feel t h a t you can ask your resident about s o m e t h i n g like that.

empathized with the ubiquitous stresses and challenges t h a t i n t e r n s face. T h e i m p o r t a n c e o f a t t e n d i n g to t h e e m o t i o n a l n e e d s of i n t e r n s w a s cited by several residents: As an i n t e r n . . , you're feeling so s t u p i d every m i n u t e of your day, you never feel like you're good or adequate. So. I think, every time someone gives you a good word s u c h as 'nicely done," it definitely helps. More t h a n o n e r e s i d e n t a r g u e d t h a t e n s u r i n g i n t e r n s '

Overall, t h e r e s i d e n t s ' e x p e c t a t i o n s o f t h e m s e l v e s i n s u p porting interns were expansive: Your role is to provide knowledge where it's missing, expertise. comfort, r e a s s u r a n c e w h e n somebody feels they are completely insecure, can't m a n a g e s o m e t h i n g , and feel frustrated, it's to be there. It's more t h a n j u s t telling the p e r s o n that X is the drug of choice for infection A a n d infection C. It's teaching t h e m to be confident in their decisions. It's t e a c h i n g them that it's OK to make a mistake.

e m o t i o n a l w e l l - b e i n g is a p r e r e q u i s i t e for l e a r n i n g : F o r PGY-2 r e s i d e n t s , e f f e c t i v e n e s s i n m i n i s t e r i n g to So, for the most part it's trying to deal with the i n t e r n ' s

the emotional well-being of interns, however, may be

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Y e d i d i a et al., Conflicting Roles of R e s i d e n t s

d i l u t e d b y t h e s t r e s s e s o f t h e i r o w n role d i s c u s s e d a b o v e . Most r e s i d e n t s a c k n o w l e d g e d this t e n s i o n . One, w h o w a s particularly r e s p o n s i v e to t h e n e e d s of i n t e r n s , c a p t u r e d t h e s e n s e o f e x a s p e r a t i o n s h a r e d b y m a n y o f h e r colleagues:

JGIM

thing that separates me from a n intern, w h i c h is w h a t I was the day before, is one day." So I didn't have a big problem saying, '1 don't know,' b u t some people do. For t h o s e w h o felt m o r e c o m f o r t a b l e s a y i n g "I d o n ' t know'" t o w a r d t h e e n d o f t h e y e a r , t h e i r c o m f o r t g e n e r a l l y co-

Suddenly, I h a d new i n t e r n s who were looking to me. I h a d no idea w h a t to do. How do I n u r t u r e t h e m ? I still w a n t e d to be n u r t u r e d . . . . There was no p r e p a r a t i o n at all.

incided with a growth in self-confidence. They believed

T h e r e s i d e n t s t e n d e d to r e s p o n d t o t h i s c o n f l i c t e i t h e r

I'm m u c h more free to say 'I d o n ' t know.' Because in J u l y . . . I j u s t sort of fudged and became flustered a n d 'Oh my God! Oh my God!" But it really w a s n ' t that big of a deal. Now it's like, 'I don't know it: let's go find out.' It's actually better for me because t h a n I can learn myself as well.

stoically o r b y f e e l i n g o v e r w h e l m e d : I felt that I was the leader, a n d I couldn't d e c o m p e n s a t e in any way. I felt like 1 h a d to stay totally calm, totally in charge, and constantly focused on w h a t ultimately was going to be the best patient care in order to get everybody else to do that. I definitely had a philosophy for a while t h a t the whole training program was s u c h t h a t you never felt comfortable with what you were doing w h e n you were doing it, that t h a t was the way it was designed. J u s t as you got comfortable doing something you were asked to do the harder, more challenging thing. It was always a s i t u a t i o n where you were overwhelmed.

t h e y h a d e a r n e d t h e s t a t u r e to a c k n o w l e d g e d e f i c i e n c i e s in k n o w l e d g e w i t h o u t l o s i n g c r e d i b i l i t y .

I feel more confident. I feel better at w h a t I do. Now I feel legitimate in saying that if I d o n ' t know, it's a tough question. It's not like I'm a n idiot and everybody in the world would know the answer. You can say, 'That's a very good question. I don't know the answer, so therefore, it's a n i n t e r e s t i n g a n d hard question.' For b o t h g r o u p s , t h e p e r c e p t i o n s o f o t h e r s w e r e c e n t r a l to t h e i r r e s p o n s e s .

In n e i t h e r c a s e d i d t h e r e s p o n s e s a t i s f y t h e r e s i d e n t ' s

The residents described very different practices in

n e e d s . A l m o s t all o f t h e r e s i d e n t s c o m p l a i n e d t h a t t h e y

exercising a u t h o r i t y over i n t e r n s . Most of t h e r e s i d e n t s

h a d little o r n o p r e p a r a t i o n for t a k i n g o n t h e i r s u p e r -

agreed that maintenance

visory responsibilities.

h o w c l o s e t h e y w e r e to t h e i n t e r n s i n a g e a n d t r a i n i n g .

Supervising Patient Care: Exercising Authority [While Acknowledging Ignorance] We a s k e d t h e PGY-2 r e s i d e n t s h o w t h e y h a n d l e d s u pervisory situations when they lacked adequate clinical knowledge; t h e y also w e r e a s k e d to c o m p a r e t h e w a y s t h e y felt a b o u t t h i s t o w a r d t h e b e g i n n i n g a n d t h e e n d of t h e y e a r . A n a l y s i s o f t h e i r r e s p o n s e s is f o l l o w e d b y a c a t e g o r i z a t i o n of t h e m e a n s by w h i c h t h e y e x e r c i s e d authority in this context. Most of the r e s i d e n t s e m p h a s i z e d t h e i m p o r t a n c e of conceding their lack of knowledge:

o f a u t h o r i t y is d i f f i c u l t g i v e n

In a d d i t i o n , t h e i r s t a t u s a s s t u d e n t s w a s v e x i n g : They don't train you to be a boss. You're always a s t u d e n t . It's hard to be the boss. As a n i n t e r n you can always say, even to nurses and o t h e r people, not j u s t your team, 'Well, it's not me. My resident said to do this.' But as a resident, you have to say to a n u r s e or to anyone else, "I want the every time, and t h a t ' s the end of it, I don't w a n t to hear a b o u t it.' So no, they don't really train you for that. Six m e c h a n i s m s

w e r e d e s c r i b e d for e x e r c i s i n g a u -

thority a n d a d d r e s s i n g the conflicts of b e i n g b o t h a learner a n d a t e a c h e r : 1 ) p i t c h i n g in, 2) p r o m o t i n g p a r t i c i p a t o r y d e c i s i o n m a k i n g , 3) i n v o k i n g s e n i o r i t y , 4) r e l y i n g o n t h e

I'm not e m b a r r a s s e d to say to t h e m t h a t I d o n ' t know the answer. I don't like people who go a r o u n d saying, sort of giving p s e u d o a n s w e r s or vague a n s w e r s j u s t for the sake of showing that they don't, you know, t h a t they know w h a t they're talking about. I d o n ' t have any q u a l m s with t h a t because I know my limitations.

s a n c t i o n o f a s u p e r i o r , 5) o f f e r i n g a k n o w l e d g e a b l e rat i o n a l e , a n d 6) a p p e a l i n g t o f r i e n d s h i p .

PITCHING IN.

Four residents

reported

that they

shared the intern's burden and believed that they could expect the intern's cooperation in exchange:

Approximately one-third of the residents were more comfortable in a c k n o w l e d g i n g deficiencies at the b e g i n n i n g o f PGY-2, a n d t h e r e m a i n i n g t w o - t h i r d s f o u n d it e a s i e r toward the end. Those more comfortable during the earlier p e r i o d r e a l i s t i c a l l y a p p r a i s e d t h e i r k n o w l e d g e a n d b e l i e v e d t h a t t h e y c o u l d n o t b e e x p e c t e d to k n o w a s m u c h at that stage: At the very beginning, people are very defensive about their new roles a n d the k i n d s of t h i n g s they s h o u l d know how to do. I was pretty realistic in realizing, 'In one way, the only

As long as I'm not going h o m e at two o'clock a n d leaving t h e m with tons of stuff, they can't be u p s e t with w h a t I'm asking them to do because I'm p i t c h i n g in. It helps the intern to know t h a t if they're sacrificing t h i n g s because there's work to be done or there's a n emergency, t h a t at least I am sacrificing t h i n g s t h a t I like to do. too . . . . I help out, and 1 let t h e m feel t h a t I suffer with them, and yet I try to stay as cool as possible. One resident commented

that some interns may take

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619

V o l u m e 10. N o v e m b e r 1 9 9 5

a d v a n t a g e of t h e r e s i d e n t i n t h i s c o n t e x t . M o r e o v e r , r e s i d e n t s c a n n o t a l w a y s a s s i s t w i t h t h e w o r k a n d a t t e n d to

thority that derives from shared knowledge. The residents frequently attempted this strategy:

their own responsibilities. M o s t of the residents tried to include interns in decision making. A d e m o c r a t i c a p p r o a c h w a s i n t e n d e d to p r o m o t e PROMOTING

PARTICIPATORY

DECISION

MAKING.

c o o p e r a t i o n a s well a s t e a m w o r k a n d w a s g e n e r a l l y c o n trasted with relying on status: I really hate to be told to do s o m e t h i n g b e c a u s e 'I'm the resident," a n d I try very rarely to do that. I give my i n t e r n s a chance to m a k e a decision. If I agree w i t h t h e m . I'll let t h e m do it. If I disagree strongly, I will say, 'No. you m i g h t t h i n k of that, b u t t h i s is w h a t ' s going to h a p p e n if you do that, from my experience or from w h a t I've learned." M a n y of t h e s e r e s i d e n t s a l s o c i t e d i n s t a n c e s i n w h i c h they could not afford to involve interns in this process, particularly during an emergency. In such cases, they

You state why you t h i n k t h a t ' s the way it s h o u l d be, you try to persuade t h e m of the m e r i t s of your way. If they do not agree, you tell t h e m t h a t as of now it's still your responsibility a n d you'd prefer to do it your way. H o w e v e r , s e v e r a l r e s i d e n t s w e r e u n s u r e of t h e i r effectiveness in using this approach, citing their incomplete k n o w l e d g e , t h e t e n d e n c y a m o n g s o m e i n t e r n s to a r g u e w i t h t h e r a t i o n a l e for c e r t a i n p r o c e d u r e s w i t h t h e h o p e of r e d u c i n g t h e i r w o r k l o a d , a n d t h e l a c k of t i m e for e:~planations. APPEALING TO FRIENDSHIP. For two residents, the m o s t c o m f o r t a b l e m o d e w a s to a t t e m p t to b e f r i e n d a n d t h e r e b y s e c u r e c o o p e r a t i o n of i n t e r n s . T h e t w o r e s i d e n t s

who relied heavily on this approach both acknowledged t h e pitfalls.

usually asserted their seniority. INVORING SENIORITY. G e n e r a l l y , r e l y i n g o n s t a t u s i n t h e h i e r a r c h y w a s v i e w e d a s a m e c h a n i s m to b e u s e d only when another approach failed (excepting emergencies). F o r e x a m p l e , if t h e p a r t i c i p a t o r y a p p r o a c h e n d e d i n u n r e s o l v a b l e c o n f l i c t , t h e r e s i d e n t m i g h t i n v o k e seniority: Often, you get conflicts. "Oh, you know, it's ridiculous," the i n t e r n will say, 'Oh, I d o n ' t t h i n k it n e e d s to be done t h a t way.' Ultimately it's your n a m e t h a t goes o n the c h a r t a n d you're ultimately responsible, so s o m e t i m e s you have to say. 'Look, this is the way I w a n t it done." B u t t h a t doesn't usually happen. Typically, t h e r e s i d e n t s e x p r e s s e d a v e r s i o n to t h i s a p proach:

I t h i n k it's i m p o r t a n t to get along in a friendly way. Like, I don't like a very u p t i g h t , a very hierarchical system. I d o n ' t t h i n k {thatl works at all . . . . I know specifically some i n t e r n s I was working with, with w h o m I was very good friends with, that felt, w h e n I d o n ' t give a n a n s w e r authoritatively t h a t . . . it shows a certain insecurity on my part. [not] my belief t h a t 1 don't t h i n k I'm autocratic. And so, t h i n g s weren't b e i n g carried out t h a t were asked: people were disagreeing with me when 1 knew I was right, a n d t h i n g s weren't done. Overall, for m o s t of t h e r e s i d e n t s , e x e r t i n g a u t h o r i t y over i n t e r n s a p p e a r e d to b e d i f f i c u l t a n d to p r e s e n t c o n flicts, e x a c e r b a t e d b y t h e i r d u a l r o l e s a s t e a c h e r s a n d learners. While considerable attention has been devoted to p h y s i c i a n s " u s e of a u t h o r i t y i n t h e p h y s i c i a n - p a t i e n t r e l a t i o n s h i p , little r e s e a r c h a t t e n t i o n h a s f o c u s e d o n t h e p r o c e s s t h r o u g h w h i c h p h y s i c i a n s l e a r n to e x e r c i s e a u thority over other health care workers in delivering care.

I never really like ordering people a r o u n d a n d telling people what to do. I d o n ' t enjoy it, so t h a t took a lot of getting u s e d to.

Residents' Recommendations related to d e a l i n g w i t h c o n f l i c t s w a s to i n v o k e t h e

RELYING

approach

ON THE

SANCTION

OF A SUPERIOR.

A

a u t h o r i t y of a n a t t e n d i n g p h y s i c i a n o r c h i e f r e s i d e n t : • . . With a n i n t e r n who's copped a n a t t i t u d e w i t h me b e c a u s e they felt it w a s n ' t indicated to the p o i n t where they d i d n ' t respect my f u n d of knowledge or s o m e t h i n g . I j u s t say. 'We have to do it.' The following day I would a s k the a t t e n d i n g a n d the a t t e n d i n g would always say, 'Yes, s h e ' s right," a n d make a p o i n t of proving it to the i n t e r n t h a t I w a s n ' t b e i n g u n r e a s o n a b l e by h a v i n g t h e m do s o m e t h i n g •

D e p e n d i n g t o o o f t e n o n t h e a u t h o r i t y of o t h e r s , h o w e v e r , was construed as an indication of weakness that could l e a d to l o s s of r e s p e c t . OFFERING

A KNOWLEDGEABLE

RATIONALE.

In contrast

to p u l l i n g r a n k , p r o f e s s i o n a l s o f t e n u s e t h e c o l l e g i a l a u -

Two suggestions

for c h a n g e e m e r g e d f r o m t h e i n -

t e r v i e w s . F i r s t , to c o p e w i t h t h e e m o t i o n a l c o s t s of t h e t e a c h i n g role, s o m e of t h e r e s i d e n t s r e c o m m e n d e d t h a t the program create support groups or establish other mechanisms

for a d d r e s s i n g

the sources of stress.

There are some i n t e r n s w h o . . , become a first-day r e s i d e n t a n d j u s t totally fall apart. It's n o t b e c a u s e they're a b a d p e r s o n or they're stupid, they j u s t d o n ' t know how to be a resident, a n d that's fine, they never were one. So acknowledge that, a n d t h e n p u t a place in the p r o g r a m to a d d r e s s that, d i s c u s s the stress t h a t people feel. the anxiety over t e a c h i n g skills, a n d the anxiety over m a n a g e m e n t . How do you m a n a g e a team t h a t c o n s i s t s of i n t e r n s a n d medical s t u d e n t s ? How do you do t h a t ? Talk a b o u t general t h i n g s o n your mind. Do t h a t before July 1 so at least they c a n go in there a n d know it's OK to feel stressed o u t a n d not know.

620

Y e d i d i a et al., Conflicting Roles o f R e s i d e n t s

S e c o n d , to i m p r o v e t h e i r p e r f o r m a n c e , s o m e resi-

JGIM

Secondary Status of Teaching

d e n t s advocated b e t t e r p r e p a r a t i o n for their r e s p o n s i bilities, i n c l u d i n g c l a r i f i c a t i o n o f t h e e x p e c t a t i o n s a s s o c i a t e d w i t h t h e i r role:

The residents

frequently

assumed

that interns"

p r i o r i t i e s w e r e c o n f i n e d to g e t t i n g t h e i r w o r k d o n e a n d l e a v i n g t h e h o s p i t a l . T h e r e s i d e n t s a d j u s t e d t h e i r ex-

It would really help to let people clearly know w h a t your responsibilities are as a resident, because nobody really tells you that. You sort of find out. Usually you get negative feedback. 'You were s u p p o s e d to do this, a n d you didn't. See t h a t it doesn't h a p p e n again." They need to let you know w h a t the rough spots are going to be, that you're aware that you're going to be the arbiter of decisions, a n d there are going to be times where you don't know w h a t to do.

pectations accordingly: If they [interns] want to get teaching from me, I'll try to teach them. But if what they w a n t is to get t h r o u g h . . . . But usually, if they're interested in j u s t getting their work done well. but j u s t getting it done and getting out, t h e n I have no problem with that. Paralleling the a s s u m p t i o n

a b o u t t h e i n t e r e s t s o f in-

terns, the lesser importance of teaching in the priorities

Team Leaders as Teachers

of t h e s u p e r v i s i n g r e s i d e n t s a l s o w a s e x p l i c i t : The academic

medical

center's

commitment

to

teaching and service has fostered a view of patients as t e a c h i n g m a t e r i a l by h o u s e s t a f f , a n d a view of h o u s e s t a f f as cheap labor by hospitals. The conflict between service a n d t r a i n i n g is p a r t i c u l a r l y e v i d e n t a m o n g i n t e r n s . O n e resident, reflecting back on her internship, reduced her role to: What do I have to do with my h a n d s to get t h r o u g h this person and get on to my next block of work?

There's my work role, and t h e n there's my t e a c h i n g role. It's a service role. If we get all the work done. t h e n I'll teach. I try to teach as we go if I get a s e n s e there's going to be time, b u t sometimes they get to be s e p a r a t e things. "We're going to get the work done, and this is w h a t we have to do." There's a tension between the work and the teaching. In s u m m a r y , r e s i d e n t s a c c o m m o d a t e t h e h e a v y j o b demands placed on them as team leaders by assigning teaching a secondary priority. Such adaptations make

M e d i a t i n g t h i s t e n s i o n is t h e r e s p o n s i b i l i t y o f r e s i d e n t s ,

the work more manageable

i n t h e i r role a s t e a m l e a d e r . I n r e c o n c i l i n g t h e c o n f l i c t s

k n o w l e d g e d , h a v e t h e i r s h o r t c o m i n g s for i n t e r n s :

and delimiting the intern's

role, t h e r e s i d e n t s

b u t , a s o n e r e s i d e n t ac-

were

p r e o c c u p i e d w i t h e f f i c i e n c y a n d r e l e g a t e d t e a c h i n g to secondary status.

Preoccupation with Efficiency

As an intern, that's a drag. All of these i n t e r e s t i n g decisions are being made, a n d you're j u s t being told to b r i n g the t u b e s to the fourth floor.

Clinicians as Teachers

E f f i c i e n c y i n g e t t i n g t h e j o b d o n e w a s a k e y a s s e t to i n t e r n p e r f o r m a n c e . T h e r e s i d e n t s r e f e r r e d o f t e n to robots and assembly lines:

M a x i m i z i n g t h e v a l u e o f t h e i n t e r n ' s e d u c a t i o n a l experience conflicted with ensuring the patient's well-being for m a n y of t h e r e s i d e n t s . H o u s e s t a f f b e l i e v e d t h a t i n -

Especially near the e n d of the [internship] year, last year, you sort of, you're very good, you're like a robot, you're very good at what you do. And you have the m i n d set of, 'Okay, I got to get the blood cultures, got to get the EKG, got to get the c h e s t x-ray.' And it takes a lot of time to do that. And once you get good at it. you're so efficient you j u s t d o n ' t w a n t a n y t h i n g else to p u t a w r e n c h into it so that it delays a n y t h i n g t h a t needs to be done, so you sort of p u t learning on the back burner. In t h i s a n d s i m i l a r s t a t e m e n t s ,

t h e r e is c o n c e r n t h a t

learning interferes with the rhythm

of the work and

t h e r e f o r e m a y h i n d e r a d e q u a t e p e r f o r m a n c e a s a n in-

terns must be afforded sufficient autonomy in taking c a r e o f p a t i e n t s to f a c i l i t a t e a n a c t i v e l e a r n i n g e x p e r i e n c e . I n t e r n s r e p o r t e d t h a t t h e p r o s p e c t s for s u c h a u t o n o m y often g o v e r n e d t h e i r choice of t h i s r e s i d e n c y . l ° The value of a u t o n o m y w a s a m p l i f i e d by t h e s e r e s i d e n t s : It's important to let interns, first-year physicians, have as much latitude as possible in order to begin to let t h e m get a feel, particularly late in the year. Early in the year, you don't expect that. You expect t h e m to do w h a t you tell t h e m to a n d not ask a lot of questions, j u s t to get it done. But later on in the year, you need to allow t h e m to start developing their own style.

tern. Other residents amplified this tension: Yet, it a l s o w a s e v i d e n t t h a t , for t h e r e s i d e n t s , p e r I find that my interaction with i n t e r n s is more . . . it's not so m u c h teaching, they're interested in j u s t doing their work and getting out of the hospital . . . it always seemed like the conferences were a h i n d r a n c e because they kept you f r o m . . . you know, you s p e n t an h o u r sitting in a conference, a n d it means you're in the hospital a n h o u r later at night.

mitting such latitude requires considerable judgment in b a l a n c i n g t h e i m p o r t a n c e of interns" a u t o n o m y a g a i n s t the clinical n e e d s of p a t i e n t s : If I can trust them, no m a t t e r how intelligent or nonintelligent they are. ifI know t h a t w h e n they don't know s o m e t h i n g they

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V o l u m e 1 O, N o v e m b e r 1995

will come to me, then I can give them pretty m u c h a free hand. As e v i d e n c e d below, t h e r e s i d e n t s c a l i b r a t e t h i s b a l a n c e b a s e d o n t h e i r e v a l u a t i o n of t h e c o m p e t e n c e of t h e interns and the clinical context. Typical in this regard was: There are some people that you would want to give them a free hand, but for the love of life, you can't. You j u s t really have to supervise them for many reasons. Number one, they haven't developed the right sense of who's sick and who's not, you can't walk away from this one, he's going to die in thirty minutes. T h i s l a c k of c o n f i d e n c e h a s c o n s e q u e n c e s for t h e l e a r n ing e x p e r i e n c e of t h e i n t e r n w h o , a c q u i r i n g a r e p u t a t i o n as u n t r u s t w o r t h y , will be d e p r i v e d of t h e level of s u p e r vised a u t o n o m y n e c e s s a r y to d e v e l o p c l i n i c a l j u d g m e n t . Residents, then, absorb the intern's workload: The other problem comes when you have someone that is j u s t not capable of doing the job that they need to do. Their knowledge is so bad that they're dangerous to patients. Having to work with that is very difficult, because basically you assume both your responsibilities and theirs. In a d d i t i o n to e v a l u a t i n g t h e c o m p e t e n c e of t h e intern, t h e r e s i d e n t s a s s e s s e d t h e u r g e n c y of t h e c l i n i c a l s i t u a t i o n in b a l a n c i n g i n t e r n a u t o n o m y a n d p a t i e n t wellb e i n g . In t h e i n s t a n c e of e m e r g e n c i e s , c o n c e r n s a b o u t teaching were temporarily suspended: When they call me I come upstairs immediately, I guess it's usually because it's an acute thing, there's not time to say, 'What do you want to do?" I j u s t take over. They literally j u s t step back and I say, "Do this and this and this,' to the n u r s e s "Start this drip. start that drip . . . . "And it's not b e c a u s e - there's just no time to sit there and teach and I think anybody would do the same thing, I don't think that is the point where I'm being inappropriate by not allowing them to make decisions. If they haven't figured that out and told me that's what they want to do, I'm going to tell them, "That's what you have to do." That's the line between education and patient care. But short of those emergencies, I'll try to help out so that they can grapple with the problem. That feels m u c h better for me. T h e r e s i d e n t s ' a c c o u n t s of t h e i r r e s p o n s i b i l i t y for p a t i e n t s a s s i g n e d to i n t e r n s w e r e t e n t a t i v e , e v e n c o n tradictory, r e f l e c t i n g t h e s e t e n s e c i r c u m s t a n c e s : On one level, they [patients] belong to the individual intern. You want them to develop that sense of, 'This is your patient. You're responsible.' But then, they're all mine. I ultimately feel completely responsible for every single thing that happens to them. This outlook requires dynamic reevaluation and adjustment, with significant psychic demands:

If you're neurotic, it's never a problem because you're always there. That's the easy way out. You've guaranteed that everybody does well, all things are done the way you want them done, but that's not correct, either, because there's never one right way. For example, in letting go a little bit and kind of seeing where they [interns] take things. It's j u s t sometimes the thing is when you're dealing with people's lives, it's very scary, and if you're a very hands-on person like I am, you're very leery about doing that. N o n e of t h e r e s i d e n t s r e p o r t e d h a v i n g s h a r e d t h e difficulties i n h e r e n t in t h e s e s i t u a t i o n s w i t h o t h e r s o r d i s c u s s i n g t h e i r a s s e s s m e n t s of a p a r t i c u l a r i n t e r n w i t h one of t h e i r s e n i o r c o l l e a g u e s . T h e y a p p e a r e d to r e g a r d d e c i s i o n m a k i n g in s u c h m a t t e r s a s t h e i r sole r e s p o n sibility.

DISCUSSION The intimate relationship between teaching, learning, a n d s e r v i c e d e l i v e r y is a n e n d u r i n g f e a t u r e of g r a d u a t e m e d i c a l e d u c a t i o n v i e w e d a s e s s e n t i a l to effective t r a i n i n g a n d q u a l i t y of care. Yet, t h e a x i o m , " S e e o n e , do one, t e a c h o n e " p o s e s p r o f o u n d c o n f l i c t s for r e s i d e n t s that may compromise their own learning experiences as well as t h o s e of i n t e r n s . T h e c o m p e l l i n g n a t u r e of t h e role c o n f l i c t s i d e n t i f i e d in t h i s s t u d y r a i s e s s e v e r a l q u e s tions: S h o u l d r e s i d e n t s b e e x p e c t e d to t e a c h at a l l ? Is there evidence that residents' learning experiences or d o c t o r i n g skills a r e e n h a n c e d b y t h e i r role a s t e a c h e r s ? W h a t is t h e l i k e l i h o o d t h a t r e s i d e n t s d e v e l o p e f f e c t i v e l e a d e r s h i p skills t h r o u g h t h e i r role a s s u p e r v i s o r s of m e d i c a l t e a m s ? Are t h e b e n e f i t s of r e s i d e n t s ' e d u c a tional roles o u t w e i g h e d b y t h e c o n f l i c t s r a i s e d in t h i s p a p e r a n d t h e p o t e n t i a l n e g a t i v e c o n s e q u e n c e s for o u t look o n l e a r n i n g a n d p a t i e n t c a r e ? In 1989, New Y o r k State' implemented new regulations limiting residents' w o r k h o u r s . T h i s r e g u l a t i o n a l s o called for i n c r e a s e d s u p e r v i s i o n of r e s i d e n t s b y a t t e n d i n g p h y s i c i a n s . If residents" roles a s t e a c h e r s a r e l i m i t e d , h o w will a t t e n d i n g s learn to t e a c h ? S t u d i e s a r e n o t a v a i l a b l e y i e l d i n g c o n c l u s i v e evid e n c e of t h e i m p a c t o n r e s i d e n t s of t h e i r role a s t e a c h e r s . We believe, c o n v i n c e d b y t h e w e i g h t of a n e c d o t a l evid e n c e a n d e x p e r i e n c e , t h a t "by t e a c h i n g , o n e l e a r n s twice." T h o s e i n v o l v e d in g r a d u a t e m e d i c a l t r a i n i n g h a v e w i t n e s s e d t h e p e r s o n a l a n d p r o f e s s i o n a l d e v e l o p m e n t of c o u n t l e s s r e s i d e n t s . S t u d e n t s a n d i n t e r n s clearly l e a r n from r e s i d e n t s , w h o a r e t h e i r f r o n t l i n e s u p e r v i s o r s . T h e r e s i d e n t s in t h i s s t u d y , in t u r n , s p o k e a b o u t t h e i m p o r t a n c e of t h e i r t e a c h i n g role in d e v e l o p i n g c l i n i c a l dec i s i o n - m a k i n g skills: W h e n j u n i o r t e a m m e m b e r s a s k difficult q u e s t i o n s , t h e y a r e s t i m u l a t e d to d e e p e n t h e i r understanding and solidify their reasoning. T h e c h a l l e n g e is to p r e s e r v e t h e s t r e n g t h s of t h e a p p r e n t i c e s h i p a p p r o a c h to r e s i d e n c y t r a i n i n g w h i l e a m e l i o r a t i n g t h e role c o n f l i c t s w i t n e s s e d h e r e . R e s i d e n c y

622

]G1M

Y e d i d i a et al., Conflicting Roles o f R e s i d e n t s

programs m u s t e q u i p r e s i d e n t s with t r a i n i n g a n d s u p port for their role as teachers, reduce a n d m a n a g e the t e n s i o n b e t w e e n t r a i n i n g a n d service, a n d develop a n d validate objective criteria for a w a r d i n g clinical responsibility to housestaff.

Preparing Residents for Their Role as Teachers Performance of t h e i r role as t e a c h e r s is complicated by the fact t h a t r e s i d e n t s , as trainees, have m u c h the same n e e d s as i n t e r n s : accessible s o u r c e s of expertise a n d s u p e r v i s i o n to r e m e d y t h e i r deficits, r e a s s u r a n c e and support in confronting uncertainties, and guidance in f i n d i n g t h e i r place i n the h o s p i t a l ' s d i v i s i o n of labor. D i m i n i s h e d t e n s i o n s m i g h t r e s u l t from: 1) more clearly d e l i n e a t i n g the e x p e c t a t i o n s a n d l e a r n i n g goals of int e r n s a n d of r e s i d e n t s , 2) offering p r o g r a m s to e n h a n c e the t e a c h i n g skills of r e s i d e n t s a n d to e n s u r e access to other expertise relevant to t h e i r role (such a p r o g r a m was initiated at NYU/Bellevue in r e s p o n s e to the f i n d i n g s reported herein), a n d 3) p r o v i d i n g s u p p o r t i n c o p i n g with the difficult role t r a n s i t i o n s evidenced in t h i s p a p e r (also i n i t i a t e d at NYU/Bellevue s e c o n d a r y to these resuits). Development a n d i m p l e m e n t a t i o n of a formal curr i c u l u m as recently r e q u i r e d by the Residency Review Committee could a d d r e s s several of the a m b i g u i t i e s discussed here by: 1 ) s y s t e m a t i z i n g the c o n t e n t of the learning experiences of each resident, r a t h e r t h a n leaving it to c h a n c e exposure; a n d 2) i n s u l a t i n g the d e m a n d s of l e a r n i n g from those of service by d e s i g n a t i n g more u n i n t e r r u p t e d time for teaching. 13-~ A useful part of s u c h a c u r r i c u l u m could be a m o d u l e d e s i g n e d to develop the teaching a n d s u p e r v i s o r y abilities of r e s i d e n t s . The distinctive problems e n c o u n t e r e d in on-the-job t r a i n i n g could be addressed, as could t e a m - b u i l d i n g a n d l e a d e r s h i p skills. G u i d e l i n e s have b e e n w r i t t e n for e n h a n c i n g residents' teaching skills ~6, 17; likewise, p r o g r a m s have b e e n described a n d evaluated. 6, is, ~6-2o Yet, m o s t p r o g r a m s implicitly a s s u m e t h a t r e s i d e n t s l e a r n t e a c h i n g skills t h r o u g h experience a n d from role models. 16, 2 1 Formal i n s t r u c t i o n is rarely offered a n d m a y s o m e t i m e s be deprecated. An a d d i t i o n a l strategy for l e s s e n i n g the t e n s i o n s inh e r e n t i n b e i n g a l e a r n e r a n d a t e a c h e r is c r e a t i o n of s u p p o r t g r o u p s or o t h e r m e c h a n i s m s for a s s i s t i n g residents i n coping with the e m o t i o n a l weight of the role. Residents also m i g h t be a s s i g n e d advisors or choose m e n t o r s to talk over stressful experiences.

Diminishing the Tension between Training and Service Reliance o n r e s i d e n t s for h i g h - q u a l i t y , low-cost labor is central to h o s p i t a l finance; l e a r n i n g by d o i n g is believed, i n North America, to be how c l i n i c i a n s l e a r n best. The conflict is a c u t e for i n t e r n s a n d severely cons t r a i n s residents" effectiveness i n t e a c h i n g t h e m . Con-

siderable a t t e n t i o n h a s b e e n devoted to the a m o u n t of "scutwork'" t h a t i n t e r n s are r o u t i n e l y relied o n to u n dertake 9, 22 23 along with the time lost for t a s k s t h a t have more l e a r n i n g value. 24 E d u c a t o r s a n d r e s e a r c h e r s have expressed the n e e d to p e r m i t r e s i d e n t s more t i m e to perform t h e i r t e a c h i n g f u n c t i o n s 16 as well as to improve the l e a r n i n g experiences of i n t e r n s a n d residents. ~4, ~4--16 Efforts tO reduce the a m o u n t of time devoted to n o n clinical work. by f u r t h e r s e p a r a t i n g the t r a i n i n g a n d the service m i s s i o n s of a c a d e m i c centers, could s i g n i f i c a n t l y e n h a n c e the e d u c a t i o n a l experience. A c c o m p l i s h i n g this will require reallocation of t a s k s a m o n g r e s i d e n t s a n d other personnel. T i m e - a n d - m o t i o n s t u d i e s of the c u r r e n t workload of r e s i d e n t s i n v a r i o u s h o s p i t a l s e t t i n g s consistently find t h a t r e s i d e n t s typically devote less t h a n half of their time to direct p a t i e n t care 5 9. 22: m a n y timec o n s u m i n g tasks could conceivably be delegated to o t h e r personnel w i t h o u t d i l u t i n g t r a i n i n g or p a t i e n t care functions. K n i c k m a n et al. 9 e s t i m a t e d that, u s i n g mid-level providers, 46% of a r e s i d e n t ' s workload could be u n d e r taken by other p e r s o n n e l . I n i t i a t i n g c h a n g e s i n the division of labor would r e q u i r e c o n s e n s u s a b o u t the level of expertise n e c e s s a r y for a b s o r b i n g s u c h tasks, as well as sufficient resources for i m p l e m e n t i n g n e w p e r s o n n e l policies (e.g., h i r i n g staff p h y s i c i a n s a n d mid-level providers s u c h as n u r s e p r a c t i t i o n e r s or p h y s i c i a n assistants). In the s h o r t r u n , these m e a s u r e s m a y seem financially impractical, b u t i n time they m a y come to be viewed as efficient a n d h u m a n e .

Promoting Graded Responsibility for Patient Care Placing a h i g h e r priority o n the medical n e e d s of p a t i e n t s t h a n on the l e a r n i n g n e e d s of i n t e r n s may deprive i n t e r n s of n e c e s s a r y experience w h e n a r e s i d e n t withholds a l e a r n i n g o p p o r t u n i t y b a s e d o n a j u d g m e n t c o n c e r n i n g the i n t e r n ' s competence. S i g n i f i c a n t a u t o n omy a n d a d e q u a t e feedback are e s s e n t i a l to d e v e l o p m e n t of clinical a c u m e n . P e r m i t t i n g i n t e r n s to l e a r n from t h e i r own experiences w h e n s u p e r v i s e d is preferable to delaying s u c h experiences u n t i l there is n o s u p e r v i s i o n . Whatever t e n s i o n b e t w e e n p a t i e n t safety a n d i n t e r n l e a r n i n g exists i n this s i t u a t i o n c a n be m o d e r a t e d b y efforts to clarify criteria for g r a n t i n g i n t e r n (and resident) a u t o n o m y . Paralleling i m p l e m e n t a t i o n of curricula, s t a n d a r d s c a n be developed for l i n k i n g clinical proficiency with levels of r e s p o n s i b i l i t y for p a t i e n t care.

CONCLUSION G r a d u a t e m e d i c a l e d u c a t i o n is u n i q u e a m o n g professional t r a i n i n g p r o g r a m s i n the m u l t i p l e a n d conflicting roles t h a t r e s i d e n t s are r o u t i n e l y r e q u i r e d to fulfill. Yet, a t t e n t i o n to s u c h conflicts as they alter the effectiveness of medical t r a i n i n g is rare. D i s c u s s i o n is

V o l u m e 10, N o v e m b e r 1995

]GIM

generally c o n f i n e d to structural i s s u e s - - h o w m a n y residents will be trained, in w h a t fields, where, and at w h a t cost. To be sure, structural c h a n g e s have c o n s e q u e n c e s for the nature of training. However, if the problems identified in this s t u d y are to be addressed and the s t r e n g t h of the a p p r e n t i c e s h i p s y s t e m is to be s u s t a i n e d , concerns about role conflicts in t r a i n i n g m u s t play a more d o m i n a n t role in future program p l a n n i n g .

8:429-35. 11. Lofland J . A n a l y z i n g Social S e t t i n g s . B e l m o n t , CA: W a d s w o r t h P u b lishing, 1971. 12. I n u i T S , F r a n k e l RM. E v a l u a t i n g t h e q u a l i t y of q u a l i t a t i v e r e s e a r c h . J Gen I n t e r n Med, 1 9 9 I ; 6 : 4 8 5 - 6 . 13. Apter A, Metzger R, G l a s s r o t h J. R e s i d e n t s ' p e r c e p t i o n of t h e i r role as teachers. J Med E d u c . 1 9 8 8 : 6 3 : 9 0 0 - 5 . 14. W a r t m a n S, O ' S u l l i v a n P, Cyr M. B a r r i e r s a n d conflicts, the service/ e d u c a t i o n c o n f l i c t in r e s i d e n c y p r o g r a m s , J G e n I n t e r n Med, 1 9 9 0 : 5 ( s u p p l ) : S 5 9 - $69. 15. J e w e t t L, G r e e n b e r g L, G o l d b e r g R. T e a c h i n g r e s i d e n t s h o w to teach: a one y e a r s t u d y . J Med E d u c . 1 9 8 2 ; 5 7 : 3 6 1 - 6 . 16. S c h i f f m a n F. T h e t e a c h i n g h o u s e officer. Yale J Biol Med. 1986: 59:55-61. 17. Kates N, Lesser A. T h e r e s i d e n t a s a t e a c h e r : a n e g l e c t e d role. C a n d Psychiatry. 1 9 8 5 ; 3 0 : 4 1 8 - 2 1 . 18. Bing-You R. Differences in t e a c h i n g skills a n d a t t i t u d e s a m o n g residents a f t e r t h e i r formal i n s t r u c t i o n in t e a c h i n g skills, A c a d Med. 1990 ; 6 5 : 4 8 3 - 4. 19. G r e e n b e r g L, G o l d b e r g R. J e w e t t L. T e a c h i n g in the clinical s e t t i n g : factors i n f l u e n c i n g residents" p e r c e p t i o n s , c o n f i d e n c e a n d b e h a v i o r . J Med E d u c . 1 9 8 4 ; 1 8 : 3 6 0 - 5 . 20, L a w s o n B. Harvill L. T h e e v a l u a t i o n of a t r a i n i n g p r o g r a m for improving r e s i d e n t s ' t e a c h i n g skills. J Med E d u c . 1 9 8 0 ; 5 5 : 1 0 0 0 - 5 . 21. Miller GE (ed). Medical E d u c a t i o n a n d the C o n t e m p o r a r y World. Bethesda, MD: DHEW P u b l i c a t i o n 7 7 - 1 2 3 2 , 1976, 22. Lurie N, R a n k B, P a r e n t i C, Woolley T, S n o k e W, H o w do h o u s e officers s p e n d t h e i r n i g h t s ? A t i m e s t u d y of i n t e r n a l m e d i c i n e h o u s e staff on call. N E n g l J Med. 1 9 8 9 : 3 2 0 : 1 6 7 3 - 7 . 23. H a y w a r d R. R o e k w o o d K, S h e e h a n G. B a s s E, A p h e n o m e n o l o g y of s c u t . A n n I n t e r n Med. 1 9 9 1 ; 1 1 5 : 3 7 2 - 6 . 24. Wallace E. Service vs e d u c a t i o n in i n t e r n a l m e d i c i n e r e s i d e n c y . A r c h Intern Med. 1 9 8 8 : 1 4 8 : 1 2 9 6 . 25. Wilkerson L, Lesky L, Medio F. T h e r e s i d e n t a s a t e a c h e r d u r i n g w o r k r o u n d s . J Med E d u c . 1 9 8 6 : 6 1 : 8 2 3 - 9 . 26. Maudsley R, Service a n d e d u c a t i o n in p o s t g r a d u a t e m e d i c a l e d u cation. C a n J Med. 1986; 1 3 5 : 4 4 9 - 5 3 .

REFERENCES 1. Ziegler A. Developing a s y s t e m of e v a l u a t i o n in clinical legal teaching. J Leg E d u c . 1 9 9 2 : 4 2 : 5 7 5 - 9 0 . 2. C l e m m o n s B. U p d a t i n g legal e d u c a t i o n : a p r o p o s e d c u r r i c u l u m e m p h a s i z i n g c l i n i c a l e d u c a t i o n . G e o r g e M a s o n U n i v L a w Rev. 1990;12:57-76. 3. Rose H, Legal e x t e r n s h i p s : c a n t h e y be v a l u a b l e clinical e x p e r i e n c e s for law s t u d e n t s ? Nova Law Rev, 1 9 8 7 : 1 2 : 9 5 - 1 1 3 . 4, B r o w n RS, H o u s e s t a f f a t t i t u d e s t o w a r d t e a c h i n g . J Med E d u c . 1970;45:156-9. 5. Nerenz D, R o s m a n H, N e w c o m b C, et at. T h e on-call e x p e r i e n c e of i n t e r n s in i n t e r n a l m e d i c i n e . A r c h I n t e r n Med. 1 9 9 0 ; 1 5 0 : 2 2 9 4 - 7 , 6. Sheets K, H a n k i n F, S c h w e n k T. P r e p a r i n g surgery, h o u s e officers for t h e i r t e a c h i n g role. A m J S u r g . 1 9 9 1 ; 1 6 1 : 4 4 3 - 9 . 7. Institute of Medicine. C o s t s of E d u c a t i o n in the Health P r o f e s s i o n s , W a s h i n g t o n , DC: N a t i o n a l A c a d e m y of S c i e n c e s , 1974. 8. S/:hwenk TL. S h e e t s KJ. M a r q u e z J T , W h i t m a n NA, Davis WE, MeClure CL. Where, h o w . a n d f r o m w h o m d o family p r a c t i c e resid e n t s l e a r n ? A m u l t i s i t e a n a l y s i s . F a m Med. 1 9 8 7 ; 1 9 : 2 6 5 - 8 . 9. K n i c k m a n JR, Lipkin M, F i n k l e r SA, T h o m p s o n WG, Kiel J . T h e potential for u s i n g n o n - p h y s i c i a n s to c o m p e n s a t e for the r e d u c e d availability of r e s i d e n t s , A c a d Med. 1 9 9 2 : 6 7 : 4 2 9 - 3 8 . 10. Yedidia MJ, Lipkin M, S c h w a r t z MD, H i r s c h k o r n C. D o c t o r s a s workers: w o r k - h o u r r e g u l a t i o n s a n d i n t e r n s ' p e r c e p t i o n s of r e s p o n sibility, q u a l i t y of care, a n d t r a i n i n g . J G e n I n t e r n Med. 1993:

e

REFLECTIONS Research

demands

involvement.

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be delegated very far.--Anonymous