The residency process has been substantially altered by work-hour restrictions. The 20th-century residency, which emphasizes taking responsibility for the patient throughout a hospital stay, has now been dismissed as “nostalgic professionalism.” Residents are now advised to avoid such activities as checking laboratory results from home and coming to work when they are not feeling well.17 However, there has been considerable pushback against diminishing nostalgic professionalism, primarily from surgeons.18 “Teaching residents that they should go home to rest at the end of their shift without regard for the circumstances of their cases in progress is not an acceptable example for training.”19 Current promulgated restrictions on duty hours move concern for the “circumstances of their cases” to the back burner—the shift ends, the physician leaves. Residents are pulled one way by forces telling them to leave (Accreditation Council for Graduate Medical Education) and the other way by forces telling them to stay (their conscience).
How do residents develop their surgical identities and concepts of humanism and professionalism? There is a substantial body of evidence that the so-called hidden curriculum is the dominant factor: trainees emulate what their faculty say and do.20 As Gofton and Regehr21 noted, “It is vital for members of the surgical academic community to recognize [that] the attitudes, beliefs, and values implicit in every action, every word, every inaction, and every silence are not only shaping the attitudes, beliefs, and values of one’s protégés, but also are shaping the decisions of students who are considering the possibility of becoming one’s protégés.” It is not easy being a surgical role model given the conflicts affecting academic surgeons. For example, should a surgeon allot extra time so a trainee can do a case properly, or should the case be finished expeditiously in order to avoid canceling the next case, or to get to a committee meeting or a kid’s ballgame on time? Monetary pressures, along with the possibility of losing operative time because the schedule was not full, can influence the decision to operate or not.22 Trainees absorb what they hear and see.
In 2003, Inui23 published A Flag in the Wind: Educating for Professionalism in Medicine, in which he stated, “There can be little doubt that physicians in general as well as the leadership of the organization of medicine have been preoccupied with finances and the economics of medical care. … The topics and the language of academic leadership [have] shifted in the last twenty years. … Core functions of the academic medical center became ‘enterprises.’” He also noted, “The most difficult challenge of all may be the need to understand—and to be explicitly mindful of, and articulate about—medical education as a special form of personal and professional formation that is rooted in the daily activities of individuals and groups in academic medical communities.”23 In addition, the “institutional environment we create … [is] a reflection of the values we hold as a professional community.”23 In effect, the academic medical center is part of the hidden curriculum.
Curiously, academic institutions tend not to reward clinical excellence—a self-defeating measure for any institution that recognizes the importance of the hidden curriculum.24 A peer evaluation of hospitalists revealed that the most highly regarded were highly associated with humanism and a passion for clinical medicine.25 At a prominent institution, however, it was found that clinical educators were less likely than research faculty to hold a higher rank.26
Of the factors affecting physician dissatisfaction, workplace stress is predominant.27 In this age of organizational physicians, job satisfaction correlates with how a physician feels about his or her ability to function as a physician. In a study by Wai and colleagues,28 “surgical faculty reported low satisfaction with a number of questions about communication in their medical schools and their clinical practice locations.” The authors indicated that “medical school and department governance are critical determinants of faculty satisfaction within academic surgical centers.” Pololi and colleagues29 extensively studied the culture of academic medicine and summarized the sources of discontent: “competitive individualism, undervaluing of humanistic qualities, deprecation, and the erosion of trust.” In another study,30 they studied the incidence (~25%) of, and reasons for, considering to leave academic medicine. Reasons included feeling isolated in the department, lack of institutional support, poor communication with administrators, and a perceived difference between the stated culture of the institution and what was observed on a daily basis.30
What Can We Do?
The obvious starting point is the selection process—focusing more on finding the “best,” not necessarily the “brightest.”15 This is not easy. Recommendation letters are often based on limited contact and may or may not reflect applicants’ true character. Numerous websites advise resident applicants on what questions to expect and how to prepare and practice for them. I have found questions of current events very illuminating, as they can probe how applicants view the world. Given the high income of orthopedic surgeons, some applicants likely are attracted to that aspect of the specialty. These applicants are not the “best.”