The glorious season is upon us. Yes, it is finally autumn. But it is also the season of ERAS with all of its letters of recommendation, USMLE scores, medical school transcripts, and personal statements.
I have dutifully reviewed dozens of applicants whose last names begin with the letters “T” through “Z.” I have noted the test scores and grades. I have considered the caliber of medical school and whether the LORs contain the terms “give my highest recommendation” versus “recommend without reservation.” I have noted that most of the applicants profess that they enjoy running, cooking and traveling as hobbies. Almost all admire the “resiliency of pediatric patients.” All of that is necessary and part of the process, but what do I — as someone who has been an associate program director for seven-plus years — really want to know about you?
1. How will you respond to adversity? You have conquered Gross Anatomy and made it through your psychiatry rotation. You have taken many tests and shown up to lots of rotations and earned at least adequate grades, and you are still standing. So you do know something about adversity. Some of you know much more than others. But I’m talking about a whole new level of stress. You will have some actual responsibility for real human lives now and notes to write and conferences to get to and nights of call. The responsibility and sleep deprivation may be a shock to your system, a slap in the face. How will you respond? Are you resilient? This word is the most important one of all. It trumps smart and efficient and empathetic. It’s the one that allows you to keep going. I wish I could assess resiliency. I wish I could teach resilience. That’s something I am working on.
2. Will you be truly responsive to constructive feedback and use it to improve your performance? You are smart and capable. You have always been at the top of the pack, at least until you started medical school. You are used to having a 4.0, getting straight As, earning five out of five on Leichhardt scales. But let’s face it — someone has to be average. In fact, most people have to be average. And let’s also consider that all of us could do better. You will receive feedback and evaluations in many forms during your time as a resident. Some will be face-to-face, some will be formal and written. Some of it will feel uncomfortable. Your attendings are tasked with helping you to improve, and if there is nothing for you to improve upon, we should allow you to finish residency early. Please try to be responsive to feedback – the vast majority of it is intended to be helpful and constructive. Although it may be a stroke to your ego to be given all fives on an evaluation with the comment — “Keep doing what you’re doing!” It is totally worthless in terms of helping you to improve yourself.
3. Will you be able to see opportunities for improvement rather than opportunities for complaint? I will guarantee you right now that there will be something, probably many things, that bother you about being a resident. I promise you that there are many things that bother me about being an attending. The real question is: What are you going to do about those things? Will they simply become fodder for complaints and bitterness or will you think about how to make things better and present your ideas in a professional fashion? I also promise you right now, cross my heart, that you won’t like the rounding process at some point. This is a universal truth. Please believe that those before you have spent countless hours balancing the priorities of all stakeholders and trying to develop the best system possible. Please also believe that we want to listen to you and make changes when we can.
4. Do you classify patient care activities as educational opportunities or as merely service? This has been a disheartening trend in my program over the past few years. Seeing and admitting patients are seen as “service.” I realize that the tasks associated with seeing and admitting patients (i.e., writing H&Ps and daily progress notes, entering orders, calling consults, struggling through complex discharge plans) are not glamorous. However, these are also the tasks I perform when I see patients who are not covered by residents. This is attending-level work.
5. Will you seek help when you need it? Residency is hard. Life, my friends, is hard. You are not expected to have all of the answers right out of the gate (or, frankly, ever). Please, please, please realize that asking questions is a sign of strength and insight rather than a sign of weakness. As a mid-career clinician, I frequently ask questions of specialists or intensivists when I am in doubt. I consult online resources. I am very sure that I don’t know everything – and neither do you. Make your best effort at finding the answer, but never put your patient at risk by assuming that you know more than you do. In the same vein, please do not hesitate to seek mental health support when you are struggling. As program directors, we can suggest this to you but cannot require it of you. Recognizing when to seek support is also a sign of strength and insight rather than one of weakness. This is critically important.
So, although I love that fact that you enjoy playing Settlers of Catan and that your boards scores rock, I want to know if you have what it takes to be a good resident. And, in my opinion, these five things are what it takes.
Lisa Sieczkowski is a pediatrician.
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