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The Resident Pain Scale

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We have a pain scale for everything. Why not one for residents and residency programs? Warning — this column is filled with sarcasm, hyperbole and an overall contempt. Read at your own risk.

There is this misconception that residents should be happy all the time and that medical training should not necessarily be rigorous or have high expectations. Really, this is pervasive about everyone at all levels in our society, but that can be the subject of another day. Every year, usually around application time, residents and (mostly) medical students approach me for advice and opinions on a variety of programs and topics related to applying to and ranking programs. And of course, since I’m a surgeon, I’ll offer unsolicited advice a lot of the time too. A lot.

I emphasize to students to pick a specialty not based on the emotions and daily grind of the associated house staff. There are a few reasons for this. Firstly, residency has a defined end and is not a lifetime sentence (although the light at the end of the tunnel is the train of attending-ship, indeed, with its boxcars of MIPS, MACRA, EHR, CPT, ABCs and ESPN.) Second, if you ask any resident they’ll tell you they work too hard. And it’s probably true… most days. I’ve seen medicine residents who worked an hour over their shift because that last admission came at 9:55 PM, which meant they couldn’t go home at 10:00 PM at the end of their shift, at least not ‘til the patient was admitted. Ophthalmology residents in the office have told me they work too much. Surgery residents of course say they work too much. Everyone works too much (including me now!). Lastly, I remember as a resident my daily emotions hinged on whether or not I still had money on my hospital card to pay for lunch. So it’s variable.

I tend to remind applicants, for better or worse, that some level of misery in training is desirable. This likely translates to exposure to cases, patient care, novel approaches, additional research, among other things. Still, it’s important to understand that true destitute misery and indentured servitude is not desirable, but some level of rigor is required. I’ve therefore designed this pain score to help people navigate some of these issues.

The pain score is of course on a Likert scale. Most importantly though, house staff are too exhausted and have much more important things than to deal with numbers. So we’ll borrow from the Wong-Baker FACES pediatric visual analog pain scale, but with a slight twist. House staff are basically children anyway. Plus, this will help candidates identify these people on the interview trail.

This is the prototypical “inmates running the asylum.” I would advise caution for two reasons. The residents either are so overly happy because they have no academic or service obligations, and can just “show up,” not know anything about the patients or medicine in general, and go home by 3 p.m., all without consequence. Or, they all have personality problems. Seriously, when was the last time you spent more than five minutes with a trainee from any medical specialty before you realized the quicksand of their conversation left you immersed in the perceived deficiencies of his program? (I said his because it is my professional opinion as a man that men whine more than women).

These residents chose their residency based on some unrelated factor: proximity to the Appalachian trail, number of tornado-touchdowns per year, etc. Overall, they are happy with their decision from an extramural perspective. You will need to corner these well-tanned and perfectly-groomed residents and push hard to learn anything about their program though. “Medical training? You mean like CPR?”

I place these in the same category. You go on an interview and everything seems overall good or acceptable. Nothing particularly is egregious except the residents just have this blasé attitude. It’s not them - it’s the fatigue setting in. You know these people are working. In the end, they will likely graduate with good training and a solid foundation. They will probably go on to good fellowships in their chosen subspecialties. They may not be able to get into the most competitive niches, but they are well positioned for their future.

This is probably the hallmark of well-beaten house staff. They avoid eye contact, questions, even maybe the interview candidates. Things are all their fault. The program is just fine, the issues are all with me! They suspect conspiracy but can’t prove it. Short of tinfoil hats, these poor shifty-eyed residents are trying to signal you to get out while you can, but they can’t be explicit because “they are watching.”

The program with these residents is not for the faint of heart. There is likely excellent training at this program at the potentially significant expense of personal health or social relationships. Time spent may “approach” work hours violations. However, high risk typically means high reward. Just don’t end up at one of these programs where their graduates don’t really go on to anything… Or they decide to switch careers and become professional scuba divers or something. This is probably your traditional “malignant” program that may have a “published rate” at which residents are fired.

These are the programs you want to immediately cross off your list. The ones where it’s clearly a prerequisite to be completely off your rocker to be a resident there. Also, these are the programs where the program says how great they are but they just don’t understand why 75% of each class every year transfers out. When your tour guide shows up, inevitably late, he looks frazzled like he only made it after being chased by rabid flying squirrels through a parking lot of hungry alligators. I would also place programs here where you see attendings that don’t wash their hands in the bathroom. That’s just bad personal hygiene and no one wants your cooties. Wash your hands, man!

Ideally, you’d like to be at a program somewhere between 5 and maybe 9 on the pain score, but that’s up to you to decide. Happy hunting and good luck!

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