This article is a response to the anonymous urology resident who recently wrote the story “This Resident Works 100+ Hours per Week, but Is Still a Poorly Trained Surgeon.” It is written by Karen L. Stern, MD, one of the chief residents in Urology at Mayo Clinic Arizona.

Dear Resident –

I am truly sorry your experience in a Urology residency thus far has been far below your expectations. I am finishing residency in June and I know how hard it is. There are sleepless nights, thankless tasks, and residency feels like a learning process that crawls forward in inches rather than feet. The frustrations are multiple and I sympathize with you that you don’t feel like you have been treated fairly.

I do, however, want to specifically respond to a few points you have raised:

- I want to make sure that readers know that your experience should not be generalized to all urology residency programs. I feel like I have received excellent training in my residency and have been treated fairly. It should be noted, however, that urology residency is still a surgical training program and being treated fairly is NOT synonymous with being consistently treated with kindness. Feedback isn’t always given in the most gentle manner, but even harsh feedback serves a purpose — to encourage change and improvement. I feel I can go to any staff in my program to express concerns in a safe and comfortable environment, and I’m sorry that you don’t have the same situation in your program.

- I work long and hard, but I still stay within the duty hour regulations. I have taken home call for the past 4 years. Some nights are definitely worse than others and long nights go right into a full day following call. There are advantages to home call as well as definite disadvantages (which you mentioned), but in-house call has positives and negatives as well. I have talked to colleagues at programs with in-house call and they are still well within their hours as well. In fact, if residents were in-house too late one day they actually were required to come in late the following day to stay within hour regulations. Programs should do a better job of explaining to applicants the call structure so that applicants like yourself could have made a more educated decision on picking a program with home call or in-house call.

- The era of complete autonomy in the operating room is gone. I do not think that is unique to your program. I think the challenge for residents now is to grow comfortable under the direct guidance of different attending physicians and gain their trust to achieve graded autonomy throughout training. It’s not fair to criticize your program for not allowing significant autonomy when you have been in urology training for not even a full 2 years. I don’t believe I was able to truly appreciate the autonomy my senior residents had when I was PGY-2 simply because my role was so different than theirs. Please also look at the issue of autonomy from a patient’s point of view.

- I do not think that the utility of gaining experience in clinic, covering floor duties, performing ancillary tasks, etc. should be ignored. Obviously, residency is more personally fulfilling if you are in the operating room all day. But one day you will be out on your own and you will be thankful for being comfortable with those patient or staff interactions that will come easily and naturally due to these non-operative experiences.

You obviously feel very strongly about your mistreatment and are making serious allegations about duty hour violations. The recent proposed update to the ACGME Common Program Requirements highlights the ACGME’s commitment to promoting a culture of wellness and well-being amongst trainees. No resident in the current era should be forced to work the hours that you do, nor made to feel inadequate, undervalued or as anything less than a future colleague. The ACGME recognizes that, and is working to implement an entirely new set of standards designed to address these very issues. They are intentionally flexible to give programs the opportunity to approach the new standards in a way that best suits each one, but similarly allows the ACGME flexibility to evaluate each program’s efforts on their own merits as they work to address a glaring problem that our culture of medicine has been allowed to persist unabated for too long. A number of programs and institutions around the country are working to this effect, by allowing residents to go home early or come in late the next day, creating dedicated ‘nap rooms’ or a back-up call system for residents who are presented with more than any single person should safely attempt to handle.

Unfortunately, an anonymous complaint on a website will not lead to any formal investigation or positive change. The ACGME (residentservices@acgme.org) has official means of hearing resident complaints and investigating possible violations. In addition, the annual resident survey that resident programs are required to give their residents provides an additional opportunity to confidentially express concerns about your program. I encourage you to visit your local Graduate Medical Education office and seek counsel on how to improve your training. The regulations are in place for a reason, and your attending physicians went into academics with your education as a main focus. I am hopeful that a concerted effort between your program leadership and the GME or RRC can result in an environment more conducive to your education.

Sincerely,

Karen Stern

PGY-5

Mayo Clinic Arizona