In medical school, success is often measured by exam scores, evaluations, and letters of recommendation. Later on, what becomes most important is how you navigate the “hidden curriculum” of physician training. The hidden curriculum is something no one talks about or will directly teach you. It is something that you may or may not have already picked up on your own. Navigating the hidden curriculum will determine how you are viewed during your residency training.
The first topic of the “hidden curriculum” is how to avoid being labeled a problem resident. Starting on your first day of residency and for the subsequent six months, most residents will have a label by the attending physicians in your program. It is just human nature to label physicians in a new residency class. Everyone wants to be viewed as a superstar resident. However, your main goal is to avoid being labeled a problem resident. This reputation will be difficult to remove and will likely carry through your residency career.
1. Never Lie to an Attending
This rule seems very simple. Why would anyone lie to an attending? However, it happens all the time. The reason is that no want wants to be viewed as incompetent, lazy, or irresponsible. Therefore most junior residents lie to hide their weaknesses or avoid ridicule. For example, when I was an attending on the inpatient medicine service, I asked one of the interns if they followed up on an echocardiogram test result on one of our mutual patients. The intern said, “yes.” I asked for the result. He replied, “Normal”. I said, “okay, we won’t need an outpatient cardiology consult.” The next day I reviewed the outpatient discharge plan and noticed that the Echo report was not completed. So I called the cardiologist department to have it read, so I could have a discharge plan. The cardiologist notified me that our patient’s cardiac Ejection Fraction was 30%. Therefore, our patient should not have been considered a discharge candidate without a thorough evaluation of the cause of his weak heart. I talked to the resident one-on-one and told him that I was very disappointed in his performance. Trust is the most important thing that you can earn from your attending. Once you lie, the trust is gone. You can overcome incompetence, laziness, or irresponsibility. However, it is very tough to earn back an attending’s trust. During our monthly residency program (GME) meetings, the attendings talk about each resident one by one. At this meeting, when another attending mentioned that our “problem resident” lied about following up on a lab test, I brought up the Echo report. Next thing you know, this resident was labeled untrustworthy and labeled a problem resident. This leads to confirmation bias and increased scrutiny that can cloud a faculty’s view of the resident. If you don’t know something be honest and say you don’t know but will find out. This can be viewed as inexperience. You can overcome inexperience.
2. Never Outshine a Senior Resident
Medicine has its hierarchy. At some point you may work with a senior resident who is not as knowledgeable, diligent, and hard-working as you are. It can be difficult to stay in your role as a junior resident. However, resist the urge to break rank, unless it affects patient care. It is very important to never outshine a senior resident. First of all, the senior resident (who you may not respect) has been in the program longer than you and may have the ear of a very influential attending in the program. For example, if an attending asks a senior resident a question on patient management, do not blurt out the answer, even if you’re right. As an attending, most times we ask questions to teach, NOT to see how much you know. Thus, if you blurt out the answer you may be viewed as a threat by the senior resident. The attending may also see you as someone who is not a team player. Honestly, it really doesn’t matter how much you know as a junior resident. What really matters during your early training period is whether you are a team player, fit into the program’s culture, and can be trusted.
Also, don’t ever disparage or bad mouth a senior resident to anyone. This includes other residents, attendings, nurses, and other support staff. This will eventually get back to the senior resident and they will talk to the attendings about your “performance”. Attendings ask for and receive feedback from the senior residents on how everything is going. Sometimes senior residents that do not like a junior resident may exaggerate clinical performance issues. For example, if a senior resident does not like someone it may be easier to highlight minor mistakes that may be due to normal inexperience of a junior resident. I am not saying you should try to be friends with all senior residents. What I am saying is that you should not outshine or bad mouth any senior resident in your program. It will get back to them and you will be labeled a “problem resident”. Attendings value senior resident input. Any senior resident can damage your reputation.
3. Never Hide a Mistake
We all make mistakes. Own them. What gets you in trouble is how you handle yourself after you make a mistake. If you lie or try to cover it up, that is worse than the mistake. It can cost you your job and career. This happened to one of the residents in our program. One of the junior residents was putting in a central line in the femoral vein when the chief resident that was supervising was called away for a medical code in the ICU. No one knows what happened, but when the chief resident came back, the central line appeared successfully placed. A couple of days later the patient had leg swelling, and a Doppler Ultrasound revealed a Deep Vein Thrombosis (DVT) and an area suspicious for a foreign object. Later it was found to be a guide wire in the femoral vein. The junior resident that placed the femoral line did not let anyone know that the guidewire was left behind. He should have let someone know right away. He finally admitted his mistake, but it was too late. The patient underwent Interventional Radiology (IR) -guided removal of the guide wire. The patient recovered with long term anticoagulation. Also the team apologized to the patient and the family for the mistake. However, the junior resident was fired from the residency program and was not able to find another program to take him. The reason is that he put a patient at risk by hiding his mistake. Had he let the Chief Resident know right away, he would have been reprimanded — but not fired. We all make mistakes. Sometimes our mistakes can harm patients. If you make a mistake let someone know right away. The one thing you never want to do is hide your mistake and jeopardize a patient’s health.
4. Never Argue with a Nurse
This one also seems very simple. No one will ever do this on purpose. However arguments between junior residents and nurses happen all the time. The reason is that most junior residents feel like that they know more than a nurse because they just graduated medical school. On the one hand, after 4 years of college plus 4 years of medical school, a resident gains a lot of book knowledge. However, residency is more about practical knowledge. Veteran nurses know more about practical medical knowledge than junior residents. I have mediated many complaints lodged by nurses against resident physicians. Some complaints are placed in a resident physician’s permanent file. Therefore it is very important to try to understand when these arguments tend to occur.
While nurses try to “cue” a junior resident with certain orders that they are accustomed to receiving, some junior residents take this personally and feel attacked. Essentially, nurses are used to common scenarios that occur due to years of pattern recognition via real life experience. Meanwhile, a junior resident tries to think through his book knowledge to justify a medical decision. For example, a patient in the ICU has a glucose of 452. The nurse calls the junior resident. The junior resident says let’s give 12 units of fast acting insulin. The ICU nurse “cues” the junior resident by asking, “do you want to consider an insulin drip?” The resident physician is offended because he is the M.D. He says, “no let’s just do 12 units.” Coupled with some insecurity and fatigue, the resident physician yells at the nurse and the nurse informs the attending physician. The attending talks to all of the nurses and asks about the resident physician’s behavior. The mediating attending talks to the nursing staff and the resident is brought up in the next residency faculty meeting.
Nurse complaints can lead to a resident being labeled a problem resident. The key is to realize that senior nurses will know more about practical medical knowledge than junior residents. You have to respect and learn from other people around you. It is easy to lose one’s temper if one feels like his intelligence or knowledge is being challenged. The key is to try your best not to argue with anyone. This can lead to you being labeled a problem resident.
The learning curve from being a medical student to a junior resident is very steep. Many of the things that you will learn will be first hand experience that is not taught in textbooks. The key is to follow these rules so you will not be labeled a problem resident. These rules will make it easier for you to blend into the program’s culture and succeed.
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Dr. Chandler Park is a board certified hematologist and medical oncologist. He’s trained at Cleveland Clinic, Indiana University, West Virginia University, and University of Pittsburgh. During his training, he served on various academic committees, including medical school admissions, residency selection, and residency review. He’s a clinical professor at the University of Kentucky College of Medicine.
