Back When I Was a Resident…

OrthoBuzz welcomes posts from residents. Have thoughts on a trending topic or recent study? Is there a “life lesson,” big or small, you’d like to share from your ortho experience? We’d like to know what’s on your mind. Contact OrthoBuzz at: orthobuzz@jbjs.org 

This Resident Roundup post comes from Sean Pirkle, MD, a third-year resident with the Department of Orthopaedics and Sports Medicine at the University of Washington, Seattle. 

Back when I was a resident, we didn’t get post-call days. We used to chug coffee and operate on no sleep until 6 p.m. the next day. There were no duty hour restrictions. We didn’t have resident unions threatening walkouts and fighting for fair pay and protected vacation days. When I was a resident, trainees hardly ever got married. Having a kid was almost out of the question. Attendings used to throw instruments across the room and shout profanities at the hospital staff. We operated with more autonomy, and we were better for it.  

I hear comments like these a lot. They’re almost said with a bit of nostalgia, a wistfulness for what was. When my attendings were in training, medicine was fundamentally different. Over the past half century, our understanding of disease processes and treatment has dramatically evolved; the rules and regulations for safe work hours are now firmly established; the old guard of medicine is approaching retirement, slowly being replaced by Millennials and soon-to-be *gasp* Gen Z.  

I have fallen victim to such sentiments, too. Since my intern year, my residency program has seen the addition of numerous advanced practice providers (APPs) to assist the interns with patient care, including handling floor pages, removing sutures on inpatients, and writing discharge summaries. The second-year residents now have protected research days scattered throughout the curriculum, and the structure of our weekly fracture conference has improved dramatically. I sometimes overhear our junior residents complaining about their experience, and I want so badly to grab them by the shoulders and shake them and say, “But you don’t understand how bad it was! You don’t know what I went through. Back when I was an intern…”  

I am confident my attendings think the same about me.  

This is the continuous tragedy of progress, in life, in social movements, in changing the culture of a profession—that we may never experience the good for which we are fighting. For the first 2 years of residency, I knew that my experience could have been improved, and I took advantage of every opportunity (semi-annual meetings with my program director, department-wide and national surveys) to advocate for change. Now that it is happening, I find myself with a half-baked jealousy that somebody’s experience behind me is not going to be as bad as mine. We fabricate excuses to justify this cognitive dissonance: “but not operating post-call is a missed opportunity to learn,” “how are they ever going to know how to discharge a patient when the APPs do it for them,” “I would have never taken paternity leave because my co-residents would have had to cover my shifts.” 

Why do we do this? Is orthopaedics not better because of these changes? On a recent episode of the NEJM podcast Not Otherwise Specified¹, medical educator Dr. Amy Holthouser suggests no, and that efforts at ongoing change are a symptom of a “culture of intolerance for discomfort,” which could result in trainees not being adequately prepared for the rigors of patient care. There is an argument to be made that no scientific evidence has been provided that wellness interventions make a difference in perceived happiness or performance on standardized tests, although this may be misguided^2–6. It probably is true, however, that improvements will eventually be taken for granted and replaced by newer, less important demands by those who know no better than what they currently have. Older generations are quick to assert that Millennials and Gen Z just don’t have the same hustle as they had, throwing around words like “entitled” or “soft,” although I think the real difference they are noticing is that younger generations have begun to wonder if sacrificing their mental and physical health must be a prerequisite to being a good doctor.  

Historically, ignoring the importance of work-life balance has, in fact, played out poorly. A meta-analysis by Rotenstein et. al found the rate of depression and depressive symptoms among medical students was roughly 27.2%⁷. The rate of suicide among practicing physicians is estimated to be 2 to 3 times that of the general population⁸. A study from 2015 demonstrated that 12.9% of male physicians and 21.9% of female physicians met diagnostic criteria for alcohol abuse or dependence⁹, and the rates of prescription drug addiction in the medical profession is also higher than the population average¹⁰. Although the definition of burnout in the medical literature is variable, studies have reported that up to 80% of physicians experience burnout in their careers¹¹. This does not happen by chance. I think part of the problem is that, in medicine, our achievements are often linked to sacrifice. By giving up our time, we gain valuable clinical exposure. The question then is how valuable is the learning experience? Does taking on more loans and doing a fourth orthopaedics sub-internship provide teaching that will not be covered in residency? Is staying over duty hours to write discharge summaries really going to make me a better surgeon? Is one clinic day more important than going to the doctor to workup the source of my intractable abdominal pain?  

When these are the battles being fought, I am not convinced that a lack of resiliency is the driving factor behind the ongoing push to make the experience of medical education more enjoyable. It would be idealistic to say there exist blanket initiatives that could be easily implemented to solve the burnout problem, but I do think that a profession dealing with problems of attrition¹² should be more receptive to ongoing change. “Back when I was a resident” is no longer an acceptable answer, and progress will require planting trees under whose shade we may never sit. And possibly shaking a few interns.  

Residents, we’d like to hear from you. Leave a comment, or contact OrthoBuzz at: orthobuzz@jbjs.org 

Dr. Pirkle is a previous contributor to Resident Roundup. Read his essay Running Out the Clock. 

More posts from Resident Roundup: 

The Roller Coaster of Residency 

Managing Your Online Reputation: Building an Orthopaedic Practice in the Digital Age 

UNMC Case Study: How Does JBJS Clinical Classroom Influence Resident OITE Scores? 

References 

1. Tough Love. New England Journal of Medicine 2024;390(7):e16.
2. Rohe DE, Barrier PA, Clark MM, Cook DA, Vickers KS, Decker PA. The Benefits of Pass-Fail Grading on Stress, Mood, and Group Cohesion in Medical Students. Mayo Clinic Proceedings 2006;81(11):1443–8.
3. Slavin SJ, Schindler DL, Chibnall JT. Medical Student Mental Health 3.0: Improving Student Wellness Through Curricular Changes. Academic Medicine 2014;89(4):573.
4. Slavin S. Reflections on a Decade Leading a Medical Student Well-Being Initiative. Academic Medicine 2019;94(6):771.
5. Garcia DI, Pannuccio A, Gallegos J, et al. Resident-Driven Wellness Initiatives Improve Resident Wellness and Perception of Work Environment. J Surg Res 2021;258:8–16.
6. Brenner LD, Wei H, Sakthivel M, et al. Breaking the Silence: A Mental Health Initiative to Reduce Stigma Among Medical Students. Academic Medicine 2023;98(4):458.
7. Rotenstein LS, Ramos MA, Torre M, et al. Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation Among Medical Students: A Systematic Review and Meta-Analysis. JAMA 2016;316(21):2214–36.
8. Rátiva Hernández NK, Carrero-Barragán TY, Ardila AF, et al. Factors associated with suicide in physicians: a silent stigma and public health problem that has not been studied in depth. Front Psychiatry 2023;14:1222972.
9. Oreskovich MR, Shanafelt T, Dyrbye LN, et al. The prevalence of substance use disorders in American physicians. Am J Addict 2015;24(1):30–8.
10. Merlo LJ, Gold MS. Prescription opioid abuse and dependence among physicians: hypotheses and treatment. Harv Rev Psychiatry 2008;16(3):181–94.
11. Rotenstein LS, Torre M, Ramos MA, et al. Prevalence of Burnout Among Physicians: A Systematic Review. JAMA 2018;320(11):1131–50.
12. Khoushhal Z, Hussain MA, Greco E, et al. Prevalence and Causes of Attrition Among Surgical Residents: A Systematic Review and Meta-analysis. JAMA Surgery 2017;152(3):265–72.