Transition points in patient care, like the handoff of a patient from a doctor ending his shift to one beginning hers, are widely recognized as periods of increased risk of error. Yet what many in medicine overlook are the hazards of transition points in physicians’ training.
Each July, new medical school graduates and other physicians-in-training enter the next stages of their careers. Ranging from interns to residents and fellows, these rising physicians participate in orientation programs as a part of periodic, ongoing transitions into new, progressively expanding clinical roles.
At every level of training beyond medical school, there is a strong assumption that these periods of transition are limited to big new beginnings, and that the trainees will rapidly settle in. Orientations tend to focus on the logistics of starting a new job, pivoting from a deluge of information about electronic medical records and human resources packets to ice breakers and password setups. After a few weeks, programs designed to aid in transitions taper off, aside from a few individual review meetings with the program director. Trainees are expected to take flight relatively independently.
Yet medical training — from the first day of med school and throughout a physician’s career — is a continuous series of transitions. Each rotation, perhaps even each day, builds upon the one before, not only with regard to competence but also in terms of the level of responsibility and extent of accountability toward patients, colleagues, and the profession. To train in medicine is to be in a perpetual state of transition, where each step brings a new set of expectations for the physician.
Trainees tend to switch rotations monthly, often having to figure out how to survive and thrive on the job while constantly adapting to new environments with new bosses and sets of expectations. As soon as they master the workflow in one rotation, they transition to the next, repeating the cycle of starting from a blank slate. The experience of trainees is more akin to punctuated equilibrium than it is to gradual evolution. What is demanded of trainees is not transition but constant transformation.
Some argue that these transitions help trainees quickly learn to adapt and gain the independence and self-motivation required to succeed in a field as arduous as clinical medicine. Many individuals thrive in this system.
Even so, students, residents, and even experienced physicians struggle with the weight and the anxiety of facing these transitions on their own. Imagine having to constantly adapt to a completely foreign environment each month and having to learn a new workflow from scratch, all the while facing expectations to provide excellent care. This may partly explain the high rates of depression, burnout, and even suicide among medical trainees.
Until the concept of transition is broadened to include the changes and transformations trainees undergo periodically, the support structure will continue to fall short of their needs.
Many medical education programs have implemented wellness curricula for new trainees to help them learn self-care strategies like mindfulness practices, cognitive-behavioral strategies, emotion processing techniques, finding meaning reflections, dealing with death and dying and more. At our institution, the Perelman School of Medicine at the University of Pennsylvania, the internal medicine intern wellness program provides four sessions during the intern year. These focus on increasing awareness and ownership of physical and psychological well-being, recognizing signs of burnout and disability, and honing effective communications skills for navigating emotionally complex scenarios.
Making self-care part of a physician’s daily life is a necessary first step. Yet, these initiatives have the potential to serve as more than Band-Aids that alleviate and patch the stresses that accompany medical students’ transitions to internship and beyond.
Implementing a peer-to-peer support structure with oversight for the various transitions that span post-med school training, whether it be rotation-to-rotation or from semester-to-semester, can better address the root of the problem. Peers who have already experienced various rotations can be the most valuable resources in orienting future residents, but currently these conversations and collegial “orientations” are unofficial.
These sessions should specifically address the most practical concerns, particularly related to workflow, that accompany each transition: What are the day-to-day tasks an intern, resident, or fellow on a particular service is expected to perform? How does the individual fit into the team’s overall workflow structure? What are the skills and tasks that are essential to maintaining the day-to-day operations?
Such matters are generally absent from the current orientation content. Including them could not only help optimize transitions and reduce stress for the staff, but could also contribute to patient care and safety.
Existing orientation programs undeniably help physicians-in-training grow more attuned to their emotions and take ownership of their own well-being. Yet they address only the beginning of the cultural transition that medicine needs to undergo.
The road to competence in medicine is long, continuous, and stepwise. Only by recognizing the challenges and potential dangers in our own transitions can we one day find ourselves transformed into the health care providers we aspire to be.
Jason J. Han, M.D., is a resident in cardiothoracic surgery in the Perelman School of Medicine at the University of Pennsylvania. Neha Vapiwala, M.D., is an associate professor and vice chair of education in the Department of Radiation Oncology and assistant dean of student affairs in the Perelman School of Medicine at the University of Pennsylvania.