Behind the Mask: Do Current Residency Programs Produce Attentive, Invested Attendings?

Usually on time for clinic, my attending, Dr. David Glaser, was 20 minutes late that morning and, perhaps I was imagining it, sipping from his large Dunkin’ Donuts coffee with a bit more gusto than usual. Apparently, he received a call from a floor nurse sometime past midnight about one of our patients who had just undergone a total shoulder arthroplasty at one of our satellite community hospitals. There was concern that the patient had developed a neck hematoma that was potentially impinging on their airway. Dr. Glaser made the hour or so drive from his house only to find that the so-called hematoma was the patient’s innocuous fat pad, quelling any fear of an impending code.

Seeing Dr. Glaser, who after two decades of practice still handled middle-of-the-night calls himself, caused me to wonder whether today’s orthopaedic residency would shape me to become the same type of attentive, invested attending as he is. Will I, like him, keep my cell phone ringer on, so that floor nurses can reach me in the middle of the night? Will I drive in to check on my patients in person? Or will I defer to the on-call doctor, a stranger who may know nothing about the procedure and the patient.

I asked Dr. Glaser how he still musters the energy to make these house calls this deep into his well-established career. He said simply that it was the right thing to do, that he treats his patients “almost as if they were family,” and that his relationship with his patients is a higher calling. For him, there was never an option of deflecting responsibility because no one else would rightfully assume that responsibility.

Work-life balance is among the forefront of priorities of my contemporaries: residents in all specialties. After all, there is a quiet revolution gaining traction across the country. Residents are unionizing [1] to demand better pay, working conditions, and improved working hours—noble intentions, no doubt. No other job is as demanding as residency, or so the argument goes.

But residency, especially an orthopaedic residency, is not just a job. It’s an education disguised as a job. Implicit in the contract of residency lies a transaction that goes beyond a salary. The return for working in a hospital is becoming apprentices, operating and practicing on someone else’s tab for 5 years. And that fact complicates things.

It’s reasonable for residents—indeed, for any employee—to be able to voice concerns about salaries or working conditions. But with residency, particularly a surgical residency, we need to be mindful of unintended consequences. Certainly, less scut work is good, but at what point will work-hour reductions and other restrictions begin to hinder our training? We develop our skills through repetition, and repetition takes time. If we cut the time, we lose the repetition.

I recently found out about a new mobile app that can be installed on my cell phone to enforce work-hour restrictions. The app would track my location to ensure that I do not spend more than our allotted 80 weekly hours within the boundaries of a hospital. Initially believing it would be an easy solution, I changed my mind when I found myself at the tail end of my work-hour allowance having only just reached the critical portion of a difficult case. Should I tap out because a mobile app told me to do so?

I thought back to Dr. Glaser, who drove an hour in the middle of the night because a nurse was concerned about one of his patients. Tapping out at 80 hours will not be possible in 2 years if I become the kind of attending I hope to become, one who believes that the commitments to my patients will not be limited by the artificial boundaries dictated by shiftwork.

But if experience in other industries is any indication [2], this sort of monitoring software is here to stay. Its adoption is a sign of the pendulum swinging toward “life” from “work” in the work-life equation.

We should hesitate to welcome these easy solutions with open arms. By changing our profession to fit us rather than allowing the profession to shape us into competent, caring orthopaedic surgeons, we give up something. Residency is temporary, but its lessons and our responsibilities as physicians are lifelong, as Dr. Glaser showed me that morning.