Welcome to Nashville, Welcome to Jackson—Reimagining Residency Orientation

The transition between medical school and residency is associated with a decline in learner empathy,^1,2 increased burnout,^3,4 high rates of loneliness,⁵ and threats to professional identity formation.^6,7 Furthermore, an elevated focus in premedical education on cultural competency, social determinants of health, and community-focused care may go unmatched once medical students become new residents, and clinical concerns take priority over nonclinical topics.⁸ But neither learning nor clinical training takes place in a vacuum, divorced from cultural context—learning is a profoundly social process. The COVID-19 pandemic accentuated social inequities,⁹ physician¹⁰ and patient loneliness, and isolation,¹¹ which contributed to burnout at levels not seen perhaps for generations. With great change (learning environment, geography, phase of learning) comes great responsibility, for present and future learners alike. To practice well, physicians must also live well, with dedicated time, space, and attention to social and historical context: even on day one. These societal and system level adaptations call for a redesign of residency orientation, a tradition universal in graduate medical education (GME).

Competency-Based Orientation, but Not at the Expense of Community

GME orientation typically covers several basics: residents receive identification badges and parking, learn to find the nearest bathrooms, and how to use the electronic medical record. This series of presentations often focuses exclusively on work-related processes, culture, and resources of an institution, rather than immersion into the place, culture, and context of the broader community. As a result, orientation at many GME sponsoring institutions risks prioritizing service before learning, workplace over community, and protocols above people—leaving trainee familiarity with the history of the surrounding community to chance. This default or “one-size-fits all” approach may also privilege clinical competency over and above cultural competency, when really learners need both. Competency-based education strives to meet learners where they are, and values lifelong learning in authentic contexts, a process that cannot begin too soon. Residency orientation should also consider how residents will acquire the tools,¹² mindset, and historical understanding to learn, serve, and care for the people of a unique community.¹³

Reimagining Residency Orientation Together: VUMC and UMMC

The AMA Reimagining Residency Initiative launched in 2019 with the goal to transform residency training for the current and future health care system.¹⁴ Vanderbilt University Medical Center (VUMC) and the University of Mississippi Medical Center (UMMC) partnered to carry out The GOL²D Project (Goals of Life and Learning Delineated), with a central aim to better align GME with learner, patient, and societal needs. Consistent with this aim was the mutual redesign of learner-centered, site-specific orientation for all new GME trainees, via high-level collaboration and weekly virtual meetings. Our aim was to systematically enhance resident knowledge, skills, and attitudes around topics such as health equity, social drivers of health, and the local history of health inequities and racism, from the perspective of institutional leaders and the community they will serve.¹⁵

“Welcome to Nashville”: Resident Orientation at VUMC

Initial planning of the work took on heightened importance with the urgent need for adaptation to accommodate social distancing during the COVID-19 pandemic. In 2021, a redesigned resident orientation debuted at VUMC, structured as 2 half-days of live and virtual content. Residents started with a presentation on “Words that Matter,” and then the microphone was handed to leaders in diversity and health equity to share the history of racism in our health care system, focused on the specific and unique history of Nashville itself (online supplementary data Table 1). Examples of covered topics included Nashville’s 4 historically black colleges and universities (HBCUs), multiethnic culture of Turkish immigrants and refugees, role in the Civil Rights Movement, and designation as the birthplace of country music. Next, a moderated session (“Neighborhoods of Nashville”) led by an experienced social worker introduced trainees to neighborhoods surrounding VUMC. Interactive sessions on leadership, health systems science, and an introduction to GOL²D provided residents with practical frameworks to apply lessons learned. We utilized an interactive case study design to facilitate resident uptake and future use of a toolkit of local resources. This toolkit (Housestaff Guide to Addressing Patient Social Determinants of Health) included an online guide with specific local resources and input from interdisciplinary care providers. It was created to give practical resources to help physicians meet complex psychosocial needs of patients and advocate to address social drivers of health as part of the care plan.

“I’m Going to Jackson”: Resident Orientation at UMMC

The goal of orientation for incoming residents at UMMC was similar to that of VUMC: to provide an immersive experience of the community in which they practice. But there were important differences. Using a flipped classroom model, orientation material was sent to residents prior to their arrival on campus (online supplementary data Table 2). This consisted of online modules, PowerPoint presentations, and interactive quizzes. Interns sat at tables in preassigned small groups to facilitate cross-specialty interaction during orientation. A small group activity involving interactive case discussions was facilitated by various faculty and debriefed in the larger group. To foster experiential learning, residents were provided tickets and encouragement to visit the Mississippi Civil Rights Museum and the Museum of Mississippi History. Residents were given copies of W. Ralph Eubanks’ book, A Place Like Mississippi: A Journey Through a Real and Imagined Literary Landscape,¹⁶ which explores the state’s difficult past and hard life of the people of Mississippi that influence the arts, literature, and music from this part of the country.

Lessons Learned

The overall feedback from GME trainees has been positive: 68.8% (95 of 138) of surveyed VUMC participants identified at least one aspect of the orientation curriculum as “most valuable,” whereas less than 1% identified any aspect of the curriculum as “least valuable.”¹⁵ Residency program leaders have similarly responded with enthusiasm. Based on our experience from the collaborative redesign of orientation at 2 institutions, we offer the recommendations outlined in the Box.

Box Steps to Redesign Orientation: A Personalized and Historical Approach (GOL²D)

1. Begin with systematic assessment of learner needs to inform a personalized approach.¹⁵ Identify goals and knowledge gaps to better design with the end in mind.

2. Determine subjects, speakers, and stories that are relevant to your specific community. Tailor your curricula to draw from both clinical and nonclinical leaders and voices.

3. Leverage the structure and timing of orientation to align with community needs, not only those of clinical learners.

4. Make iterative changes based on feedback. Your orientation program should evolve according to learner and system needs, which (by definition) must change year to year.

5. Balance clinical content with contextual understanding. A sense of inclusion and belonging is broader than those you work with; it is about who you care for and the community where you live and serve. New learners require orientation to the community, not only the workforce.

The complete story of orientation can only be told through a chorus of voices (patient and physician, community members and leadership, past and present, one health system together with another). How will your institution lend its unique voice to this music, and build upon the time-honored history and sounds of Nashville and Jackson? By following these recommendations, institutions can strive to reach beyond an absence of burnout: they can aim for their residents to flourish.¹⁷ We invite you to reflect on the unique history and culture that make up and surround your institution. Join with us as we orient learners to better serve our community by grounding them in an historical understanding. A residency orientation that is intentionally designed to reflect community and awareness of the past will better position fledgling learners to care for patients in the future.

Editor’s Note

The online supplementary data contains residency orientation session titles and roles of presenters for Vanderbilt University Medical Center and University of Mississippi Medical Center.