The Spirit of the Matter: Morale in Neurology Residency Programs

Regardless of the myriad factors that might differentiate residency programs in the eyes of the current residents, faculty, and program directors, there is only one question that universally occupies the minds of prospective applicants: “Are the residents in this program happy?” Discovering the answer to this question is not a straightforward process. The applicant might quietly observe the individual residents or their interactions with one another to assess sociability and camaraderie, or she might ask one the question point blank and listen for sincerity in the answer. She might weigh the responses to a question regarding the good and bad aspects of each program in the eyes of the residents. Or she might look for particular perks that she knows will make her happy: reasonable work hours, dedicated mentorship, the opportunity to teach students, etc. However, the astute applicant knows that there is no way she can fully grasp the character of a resident’s experience from the spectacle of an interview day. As she fills her rank list, she wonders what makes a resident happy and whether the program satisfies the needs and desires of its residents.

Of course, in traditional medical training environments, needs are the purview of the faculty and desires are a secondary objective, the icing on the cake. In the eyes of a senior attending, a resident needs a rigorous, all-encompassing, militaristic training. There must be an obsession with perfection (whether intrinsic or extrinsic). More work is not punishment; it’s dedication. A resident is like the blade of a knife: she must be honed and sharpened, but this inevitably cannot happen without guidance from a strong arm toward a hard rock. Some, if not all, of these views are shared by many residents, particularly as rapidly changing work hour restrictions and efforts to protect new residents (and patients) further accentuate the learned forgetfulness of the brutal, early training experiences of more senior resident physicians. In this school of thought, asking for help or complaining about fatigue or excessive work load is a sign of weakness. The drive to perform comes from passion born of commitment, not of love for the job. Concepts such as resident happiness, job satisfaction, and morale often do not occupy the minds of residency program leaders and may not, by themselves, seem to be worthwhile investments at the expense of other program objectives.

The benefits of improving morale, however, are tangible and considerable. Neurology, in particular, is a field that until recently has traditionally had great difficulty in recruiting young physicians-in-training. Neurologic diseases are considered by students and residents to be difficult to understand, and the quality of the teaching of Neurology often worsens between preclinical and clinical years, suggesting that Neurology clerkships are likely not effective in inspiring students to pursue Neurology as a field [1]. Recruitment might be improved by modifying student experiences with preceptorships and more direct involvement with faculty members [2]. However, generating interest in Neurology among clerkship students and recruitment of the most attractive potential applicants may both arise from closer attention given to the needs of Neurology residents.

What do Neurology residents need to improve their morale and happiness? According to the surveys conducted by Adair et al., morale was most closely linked to supportive relationships between the faculty and residents and among the residents [2]. While support may be fostered in a variety of ways, this most certainly incorporates components of regular feedback (with both constructive criticism and encouragement), representation of the needs and concerns of residents with the program leadership (i.e. the knowledge and convincing belief that their concerns are being acknowledged and addressed), and a cohesiveness among residents generated either by frequent social interaction or a strong internal work culture (or both). Put more simply, residents who believe that they are being supported are more likely to share their interests and enthusiasm for Neurology with clerkship students, support one another in times of difficulty, and feel happier and more motivated to pursue clinical excellence in their training venue. Residents who feel unsupported are probably more likely to ignore or fail to interact with students, protect themselves and avoid opportunities to alleviate the burden of another resident, and feel unhappy and less enthusiastic or energetic to pursue the work that is “beyond the call of duty”: calling a patient after work hours, spending extra time giving individualized and meaningful feedback to students, and taking extra steps to ensure that the best clinical care is coordinated and delivered (leaving nothing to chance).

This feeling of support inevitably rises to the foreground in the answers to questions posed by prospective applicants regarding resident happiness. While the reputation (prestige) of a program and geographic location are important determinants of the initial selection of programs to which a fourth year student will apply, the interactions of the applicant with current residents and faculty members is the deciding factor in the ordering of programs on the rank list [2]. It is now common knowledge among residents, residency applicants, and astute residency program directors that the most important part of the interview day is the casual dinner the night before (or a similar event on the interview day) when the residents can freely socialize and express their sincere opinions on the program. It would logically follow that the most effective method a program director has at his disposal to recruit the most attractive applicants is to attend to the morale of the residents and their perception of support.

References
[1] Zinchuk AV. Attitudes of US medical trainees towards neurology education: “Neurophobia” – a global issue. BMC Med Educ. 2010 Jun 23;10:49.
[2] Adair JC, et al. Survey of training programs’ means for promoting neurology and attracting trainees. Neurology. 2006 Sep 26;67(6): 936-9.

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