Tl;dr: A residency program must cultivate a collegial and respectful work environment if it hopes to achieve maximum efficiency, recruit the strongest candidates, earn excellent patient reviews, establish and maintain an impressive national reputation, and reach the fullest potential of its residents.
Greetings. I’ve often considered how the culture of a training program affects the overall training experience. As a third year OMFS resident, my own experience has not been what I was promised as an extern. I’ve spent countless hours examining the ideas of healthy vs toxic work environments, determined to make a positive mark on the future of my program before I’m finished. Obviously, any discussion of my personal history within a toxic culture is highly subjective, biased, and ultimately not productive if my goal is to persuade readers that a positive culture is the objectively superior choice for leadership within our small community. Similarly, it is not productive or relevant to provide specific examples of the physical, psychological, or emotional abuse endured by myself, my co-residents, or my friends/acquaintances who are residents at other programs. Rather, my intention is to influence future OMFS residents to foster healthy and respectful cultures within their programs so that future intern/lower-level classes will not have to experience the absolutely pointless debasement, humiliation, and exploitation for themselves.
While OMFS recruits candidates who are intelligent, hard working, and usually likable, these qualities don’t exactly speak to leadership and teamwork, qualities I deem are equally as important. As a dental student, I asked an OMFS program director if leadership experience was important in an OMFS applicant. I was told “no.” Programs are more interested in knowing that you are prepared for the hard road ahead than caring about your leadership background. Thus it happens that programs accept residents who may be lacking important qualities that would later foster healthy work environments. They may accept residents with little to no leadership experience, expecting to mold the residents to lead in their own way. This works well when programs have strong directors and teachers who invest effort into building and maintaining every link in the resident chain. But that isn’t always the case. Additionally, programs may accept applicants whose super-sized egos may make it difficult to accept and eventually direct criticism in ways that foster team effectiveness, morale and true education. Making matters worse, these are the same individuals who, if treated poorly as junior residents, will repeat the cycle, wielding their authority as senior residents in abusive ways that are toxic to a healthy learning environment.
This article, however, is not meant to be a how-to manual for conducting interviews or a disquisition of the interview process, itself. Regardless of what kind of apples we have in our bunch, programs should be able to rise above individual personalities to provide a stable infrastructure necessary to support and maintain a positive culture within the program. This structure should be able to withstand the test of time, to see the comings and goings of years of residents in smooth transitions while maintaining the integrity of the program. And just as the walls of a house are built on a strong foundation, the strength of a residency program is built on its attending physicians and directors in continuous leadership positions that define the “walls” of the program. These people benefit every bit as much as the well-trained intern or the confident and qualified resident. I firmly believe that leadership starts at the top and that the quality of these individuals, along with their combined commitment to education, can deliver the environment for a highly successful program. Without these strong leaders or their synergistic efforts, individual resident personalities that rise up through the ranks are left to fill the voids, potentially leading to toxic cultures that result in so-called “malignant” programs. It should behoove ALL program participants, attendings and residents alike, of all motivations and egos, to constantly work towards a positive work environment. No matter what you want out of a program, you’ll have more benefits and success if you have a well-functioning team.
My argument is simple and straightforward: it pays to have happy team members. The medical field is immature in this regard, but in the business sector, companies know all too well that employee happiness = success and profits. Perhaps this discrepancy has to do with the opportunities employees have to seek other employment options at any given time. As a result, businesses seeking to maintain their productive work forces are more invested in employee satisfaction. This is in stark contrast to residency programs, in which the residents are locked into their programs for the next 4-6 years. Think of the convivial recruitment officer at your neighborhood armed services center and the resulting time in boot camp shortly thereafter. Residency is boot camp, except that trained sergeants in boot camp understand the importance of morale to the success of their group. Not surprisingly, the morale of residents is often taken for granted by their “leaders.” [Although I wrote this article as an opinion piece, supporting articles and their cited studies can be found in online magazines such as Harvard Business Review, Forbes, and Entrepreneur. The research is unequivocal.]
Reasons for encouraging a positive workplace environment in residency programs are almost too numerous to mention. Instead, I will take this opportunity to highlight the five factors I consider to be most important: improved productivity, better quality work, more compelling recruitment, increased patient satisfaction, and stronger resident education.
Productivity is one of the most compelling and applicable arguments for a positive culture in residency. As a senior resident or attending, even if you don’t care about the happiness of the junior residents, they will still get more done for you if they are happier. It should come as no surprise that people who are happier will be more invested in their work. A lack of motivation is a hurdle that most OMFS programs do not have to manage; OMFS residents are incredibly motivated individuals who have earned the privilege of 4-6 intense years of sleepless nights and stressful days because they know the reward will be worth the time and effort. However, when these individuals are beaten down by lack of sleep, food, respect, autonomy, independence, and free time, and they have to suffer constant humiliation and degradation, the productivity of each and every one of them will drop. People who are miserable will not be motivated or enthusiastic to carry out their jobs. They will go through the motions. They will produce less.
In a similar way, people who are happier will also give you a better quality of work. Automotons will care less and less about the quality of their work. My co-intern and I had no choice but to try motivate each other to do our “jobs” as we were receiving negative feedback multiple times a day (every single day) and absolutely zero positive feedback. This constant negativity naturally results in the perception that, “if we can’t do anything right anyway, why bother trying?” This phenomenon is rampant within residency programs. I am not providing this example of negativity to complain, but only to point out how constant negativity is not productive or efficient for the overall program. Treating people better and promoting a more positive culture will pay off in the overall enthusiasm and a healthier attitude of the residents, which in turn, positively affects the amount and quality of work accomplished.
My next point needs so little explanation as it is glaringly obvious: externs will be deterred from toxic cultures. A program needs to be attractive to applicants in order to recruit the best and brightest. If strong applicants cannot be recruited, both the program and its reputation will suffer.
The next argument can be made by answering a question: would you rather trust your health to a miserable, beaten down doctor? Or to an upbeat, confident one? Toxic environments take their toll on residents’ confidence, focus, performance, and personalities/“bedside manners,” among many other qualities. Patients do notice, and your patients will feel more secure in their care and satisfied as consumers if they are treated by residents who feel good about themselves.
My last topic is the most important to me: the residents’ education. I am a team player and more than happy to help with the busywork tasks of running an OMFS service. Nonetheless, I joined a residency program to become the best oral and maxillofacial surgeon I can be. There is no doubt that the stress, drama, and negativity of a toxic culture interferes with residents’ education. It is a testament to the fortitude of OMFS residents that our main concern is our education, rather than our well-being. We will endure all types of treatment if we know we will come out of it as a respected, confident, competent, and skilled oral surgeon. We want to change the culture not because we want to be happier, but because we want a stronger training. One that is not robbed by the drama of a toxic workplace. Four years is a short amount of time to learn the vast subject matter of OMFS. We do not have time or energy to waste on drama.
The inevitable detriment to residents’ training as a result of a toxic culture is ultimately why I decided to write this piece. Take a story that was relayed to me by a fellow OMFS resident: at the end of the year when it was time to collect program feedback, the resident informed the attendings that the “drama” of the year had negatively impacted and resolutely interfered with his education and training. The attending’s trite response: “while being an intern is difficult, it builds character.” To the resident, this was exactly akin to the “you’ll shoot your eye out” response to Ralphie Parker wanting an “official Red Ryder carbine action, 200-shot, range model air rifle with a compass in the stock and this thing that tells time.” The deflating response did not at all address concerns about the quality of his education, which is what truly suffers when energies are consumed by negativity or drama. The resident may be more resilient, more callous, tougher, or whatever the attendings intended for his “character” development, but he will never get back the time or those same opportunities to learn surgery— time that was instead spent dealing with rampant, unnecessary and gratuitous drama. The lack of a positive culture had a direct impact on the quality and quantity of his training and education.
In conclusion, we’ve discussed several of the benefits of a positive culture in training programs. If there’s a single question that remains, it should be this: how can you, as potential future residents, help to cultivate a productive and positive work environment among each other? I realize this should be the topic of an entirely new article, but I would like to make a few suggestions with regard to working with your fellow residents: teach each other, learn from each other, support each other and forgive each other. Everyone is trying to learn and grow, and everyone will make mistakes. You will let down your team and they will let you down. These disappointments are the seeds of negativity that are allowed to grow between people and classes. Forgive your chief for piling more work on you because he’s inundated, himself. Forgive your intern for forgetting to do one of his million menial tasks while suffering a seemingly relentless lack of sleep. Forgive yourself for dropping the ball this time and vow to follow through next time. And please, when it becomes your time to be a senior resident, use your rank to perpetuate positivity. Do not forget the power of a healthy culture. You will only get the best out of residency if your team does, too.