A Vote To Reimagine Residency

I can't say I knew much about medicine when I decided to become a physician. There were no physicians in my family. I had yet to learn about cells, anatomy, or antibiotics. I didn't watch ER. I had no concept of health insurance, deductibles, or co-pays. But I understood fairness. And, as a young boy in Colorado, I watched loved ones—with addiction, cancer, and other ailments—suffer the misfortune of illness and the injustice of unmet medical needs. I saw in medicine an opportunity to find voice and to remedy the unfairness around me, to address failed policies.

Medicine and Politics

On November 8, I cast my first vote as a physician, having started residency in internal medicine in June. I waited in a long line, inside the local public housing authority, surrounded by men and women of all ages and vocations. No one spoke of Hillary Clinton or Donald Trump. But everyone exuded quiet excitement and appreciation for the opportunity to vote — to give voice to their convictions.

I rushed from the voting booth to my clinic to see patients. I slipped on my stethoscope and badge, placing my "I Voted" sticker over my name, eager for a more unified and harmonious nation. I examined a patient with an upper respiratory infection, carefully listening to her lungs as she took deep, measured breaths. I counseled another patient on diet and exercise, as he described escalating stressors at home.

But, on this day, my first professional act was my vote. Medicine and politics, after all, are inextricably connected. This connection has informed and motivated physicians for generations — many years before health care reform dominated American politics. Overwhelmingly, health is a product of housing, education, employment, and food, all integral parts of the political enterprise.

These are uncertain times in medicine, largely due to politics. The fate of the Affordable Care Act remains unclear. More than ever, we need physicians to mobilize and advocate for the health of our society. We need to use the collective voice, imagination, and energy of physicians to serve as a bulwark against the changes to come.

Challenges Facing The Practice of Medicine

But as important as it is to look outward, we must also look inward at our own profession and institutions. For physicians to help heal a divided nation, we must mend our own hearts and address the epidemic of burnout. For physicians to speak out on national events and policies, we must win greater voice and clout within our own hospitals and clinics. For physicians to imagine a better tomorrow for all Americans, we must challenge our own orthodoxy and improve the status quo in medicine.

Any attempt to examine medicine must start with residency. As a resident, I am situated between the past and the future of medicine. I am shaped by the practices and norms of physicians from prior generations, while complying with inherited decisions about the nature of residents' work. At the same time, I am surrounded by peers—bright, idealistic residents—who will comprise the workforce in medicine for years to come. The key to looking inward, to strengthening our profession and institutions to better engage with the challenges around us, lies with residents, the link between what medicine is and what medicine can be.

My journey into medicine—like so many others—started with the realization I needed voice to improve the lives of everyday people like my loved ones. Above all else, I wanted to shape decisions about what we do, as a society, for those with illness. The failed policies I witnessed as a young boy in Colorado remain important. But I have realized, to look outward and improve society, I must start by fighting for greater voice among residents.

The pace of change in medicine will be inadequate without the energy and participation of its emerging generation. And, without change, medicine will fall short in training healthy, impassioned leaders ready and empowered to improve health care and advocate for broader social change.

While we revel in the promises of scientific advancements like personalized medicine, envisioning future applications and benefits, we fail to think imaginatively about our own workplaces, the very sites where medicine unfolds and residents are made. For too long, the economics and politics of health care have muted resident voice, limiting residents to an affordable, flexible, and restrained workforce.

Reimagining Residency

It is time to join together and recognize the collective power of the nearly 30,000 physicians who begin residency each June. It is time to reimagine residency, to create the conditions necessary to train physicians who can hold health care accountable for its promise of compassionate, high-quality care. It is time to acknowledge that, as individual residents, we are ordinary, but together we can push for extraordinary change.

The most immediate opportunity is around work hours. On November 4, the Accreditation Council for Graduate Medical Education (ACGME) proposed to increase the total number of consecutive hours first-year residents are allowed to work — from 16 hours to 28 hours. There is no clear answer to how much residents should work. But what is clear is resident voice is largely absent in the debate. ACGME has opened a 45-day public comment period, which ends on December 19. All residents should take this opportunity to weigh in and be heard.

But we must also look beyond the immediacy of work hours and start a broader conversation about residency. We must call into question how we work — at computers and away from patients, encouraged to document and bill more than reassure and heal. We must call into question where we work–– almost exclusively inside the hospital, away from the social determinants of health. And we must call into question why we work — to deliver financial returns to large organizations more than maximize learning and clinical preparation.

We must deconstruct the implicit objective of residency: to create standardized workers that fit into the status quo, while recognizing we can push for alternative objectives. Let's instead train physicians ready and capable of overhauling and strengthening health care from the inside. This vision goes far beyond how many hours we work — and demands new accountability from residency programs and hospitals. Patients, after all, deserve more than endurance.

When I reimagine residency, I envision training that doesn't stop at clinical decision-making and also focuses on how I communicate and lead multidisciplinary teams. I envision training with more time dedicated to learning and to sitting alongside patients, not at a keyboard — made possible by investment in additional staff to support residents. I envision a workplace where resident wellness is actively fostered—through food, scheduling, and benefits—and considered vital to the care we deliver.

As residents, we are scattered across the United States, working long hours in grueling environments, isolated even from those around us. But let's start a conversation together on Twitter, Instagram, and Facebook. Share how you would like to #reimagineresidency, in order to improve medicine and, in turn, our ability to care for our patients. This is a step in the right direction, but, ultimately, we will need to go beyond individual voices and form collectives within our own institutions, to amplify our voices and push for real change. I may not cast another vote for President until 2020, but, for now, I choose to vote to reimagine residency — and to invest in the power of physicians to improve health care and society at-large.

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