I stepped into the workroom to announce the start of rounds. My 2 interns sat hunched at computers, scribbling on “scut” sheets. I paused. A few days prior, I had been in their shoes. Now, as a new second-year resident, I was (ostensibly) their supervisor, teacher, advocate, and coach. It felt daunting.
Newly hatched physicians looking to launch smoothly from medical school to intern year will find troves of literature to guide them.1–6 However, the progression from the first to the second year of residency is less explored,7 despite representing an equally abrupt shift, with most residents assuming new roles that span education and supervision of more junior colleagues and team management.
We benefited from a leadership retreat our residency program holds every spring to help each class of 60 interns navigate their upcoming transition. One exercise from this event proved particularly illuminating. A faculty moderator invites the interns to articulate qualities they like (and dislike) in their residents. The trainees generally call out their “cheers” and “jeers” to laughter, clapping, and sympathetic groans. These lists, collected and preserved by program leadership, demonstrate remarkable consistency across years. The observations offer wise advice for interns transitioning to residency. In this Perspective, we distill this advice from 7 years of compiled lists into 10 steps.
1. Set Clear Expectations
Nearly every list from our 7 years of retreats includes the word expectations. The best residents, interns said, provide clear expectations; the worst become frustrated when interns fail at tasks that were never explicitly assigned. Many residents get off to the right start by sending an introductory e-mail to their interns before each rotation. These residents often save a version of this e-mail, and modify it as needed (for an example see the online supplemental material). At the first in-person meeting with a new team, expectations from the e-mail can be highlighted and any questions addressed.
2. Give and Receive Timely, Specific Feedback
“Don't defer feedback!” was a common request, emphasizing the distinction between real-time feedback (eg, correcting mistakes, calling out good habits) and end-of-rotation feedback (eg, outlining general strengths and broad areas for improvement). Studies have suggested that learners will be less receptive to summary-type feedback if their supervisors/mentors have not established credibility and rapport by providing ongoing, real-time feedback.8–10 So, residents should offer interns suggestions for correcting problems the moment they arise. As an expert puts it, “Catch people doing something right,” and reinforce it immediately.7 Praise positive behaviors in public; offer suggestions for improvement privately.
Residents should ask their team members for feedback and not respond defensively. Criticism can sting initially, even if it is offered in kindness; one can learn from it once some time has passed.
3. Empower the Interns
“The sweet spot balancing autonomy versus supervision changes over the course of the year, and also from intern to intern,” a contributor commented. Trust between residents and interns depends on many factors (eg, perceived skill level, patient complexity, time of year), and evolves over time.11 Initially, interns will struggle with simple tasks—residents should resist the urge to take over, put in orders, or micromanage (see step 4). It may be helpful to see oneself as the consulting physician. In work rounds, don't interrupt, except to teach or add a crucial detail. In preparation for attending rounds, discuss complicated cases in advance with the interns, so they can shine. As the year progresses, interns will be able to manage increasing autonomy.
4. “Micromanage . . . Surreptitiously”
This phrase is lifted verbatim from our lists. Ronald Reagan was fond of quoting a Russian proverb: “Trust, but verify.” Experts sometimes call it “backstage oversight.”12
Check orders, read notes, talk to the nurses, but be discreet. Interns may learn the most when they have the illusion of autonomy. Medical educator Brendan M. Reilly, MD,13 quoted a William Penn aphorism: “Let the people think they govern, and they will be governed,” adding that “teaching democratically is all about activating learners' initiative while protecting them from themselves.” In other words, a good resident manages interns by encouraging them to feel the responsibility of independent practice, while never allowing them to make serious errors in patient care.
5. Promote Wellness
“Recognize when an intern is overwhelmed before he or she decompensates,” wrote an intern. Good advice, but identifying signs of burnout isn't easy. Watch for cynicism, decreased expression of empathy, and upticks in errors. If concerns grow about an intern's mental health, talk to a supervisor.14,15 Meanwhile, create a supportive environment, and ensure interns go to conferences, eat well, and are able to leave work on time.
6. Come Prepared
The best residents organize each day in advance. Interns should propose a plan for each patient; residents should know whether they agree. A resident's own plan should also include disposition issues that may not have occurred to the intern.
Know which interns have the most work ahead of them each day. Know the sequence of patients being seen that morning. Know when and how teaching will be incorporated.
Interns expressed a desire for efficient, organized, patient-centered teaching. The best clinicians make it look effortless, but effective teaching requires skill, preparation, and practice. Work to master some high-yield teaching techniques (provided as online supplemental material).16–21
Grab teaching opportunities on the fly—an intern will remember a 20-second teaching point if it relates to his or her patient. Talking through decisions aloud in an urgent situation can turn an emergency into a learning opportunity. Experiment with teaching techniques, but always teach.
8. Pitch In
Interns perceive a resident's offer of “What can I do?” as hollow. They preferred residents who simply assume tasks. Identify the least pleasant job on the intern's “scut” list, and consider doing it. Not every day—but when things are tough.
On a related note, interns listed surfing the Internet and “disappearing” among notable “don'ts.” Interns know when residents are not working as hard as they are. They resent this behavior, and the entire team suffers.
9. Be a Role Model
“Residents should provide order (even during the deluge), and teach interns how to create that order,” a contributor wrote.
A resident who projects anger, contempt, or panic will find his or her team mirroring that emotion. So, it is important to respond courteously to the nurse who interrupts. Take a few breaths before walking into an unstable patient's room. Do not shout, ever. If feelings of rage, distress, or overwhelming anxiety arise, take a “time out.” If these feelings persist, get help.
As esteemed medical educator Charles Hatem, MD,22 is fond of saying, “You cannot not teach.” Interns and medical students watch your behavior and learn.
“Don't forget to communicate with the intern about changes in plans,” a contributor noted. Others highlighted closing the loop and frequent updates as essential in team-managed patient care. The hardest part of communicating may not relate to talking. “Be approachable, available, present,” was a suggestion. Another noted, “Be a human being.” Check in, especially when patients are difficult, complex, or very ill. Listen. Support. Empathize.
Back in the workroom, I stood staring with trepidation at the new physicians under my supervision. I thought about the residents I admired, and said in a voice I hoped expressed friendly confidence (and didn't shake too much), “Okay folks, let's get started.”
Editor's Note: The online version of this article contains a sample expectation-setting e-mail and a list of articles to aid clinical teaching.