Questions I Wish I Asked FM Residency Programs
Medical education is a never-ending power play: you are either above somebody, or below somebody. The constant inadequacy we feel says more about the hierarchical culture of medicine, than it does about who we are as human beings. As a result, we never feel comfortable asking questions that matter to us the most during residency interviews. In some specialties, it seems much more important to get into a residency than it is to make sure the learning environment is ideal for the candidate. But I hope you know that family medicine is not a specialty like that. The scope of family medicine is broad, and the emphasis of the practice is the whole person (sometimes the whole family). It’s of the utmost importance for you, the future FM resident, to land in a program that facilitates your professional and personal growth.
Here are some questions I wish I asked the FM residency programs during interviews. (Also some good questions to ask, in general.) Pardon my honesty.
Is the program (truly) unopposed?
Being “unopposed” means the FM residency is the only residency in the training hospital and clinic. And the FM residents are “the residents”, not just the FM residents. This is important because you would want to know how many people are “competing” for the learning cases when you are on your rotations. For instance, when on OB rotation, are you competing with the OB residents for deliveries? Would you be able to first-assist C-sections, or does the OB resident first-assist, and you just stand around? On pediatric rotations, can you manage sick kids, or do you just get the well child checks?
Some opposed programs have ways to protect their residents from having to compete for cases. But if your ambition is to be as hands-on and involved in every rotation you go to, an unopposed program might be your best bet. Ask this question not just to the program directors or attendings, ask the residents (during interview dinners without the attendings).
Are residents respected as physicians among staff in the hospital/clinic?
This question is so important. Essentially, you want to know if the residency program has a “vicious'“ or “malignant” culture for the residents. In my training program, the residency team takes 1 in every 4 admissions during the day, and 1 in every 3 admissions at night. We were the only team that admitted pediatric cases. We caught all the babies, and were one of the only teams that followed our own patients into the ICU. And at night, our attendings were not in house. The night shift team was made of only the senior resident and the intern (first year resident). What does this mean? It meant that residents carried real work load and generated vital revenue for the hospital. We were not just the “learners” whose each order had to be double-checked by the attending, be it Tylenol or compression stockings; we were doctors taking care of patients. The staff took us seriously, called us “Drs”, and paid us the same respect they paid the attendings. This made residency so much more tolerable.
In some hospitals, this is not the case. Staff roll their eyes when they get orders from the residents, and people bypass the residents to make decisions even though the residents are the ones writing all the notes. Nothing discourages learning than being trivialized.
Can you give me an example of when a faculty/senior resident stook up for a resident/intern?
If you have the chance to meet the intern class, the ones who are the “lowest on the totem poll”, ask them this question. What you are essentially asking is, when a resident is mistreated (which will happen, anywhere you go), is there a culture to demolish that kind of behavior?
Here is my own example. When I was an intern, one night, I spent all night managing multiple laboring patients, while also doing hospital admissions, and answering pages about patients on our service list. I carried 3 pagers, and I was running around the whole hospital all night. To make matters worse, my mother had come from China to visit me in the US, and she wanted to spend time with me, so she decided to stay the night with me in the call room, in case I had “down time”. I didn’t. Then at the end of my shift, I found out that all the laboring patients I admitted and managed had delivered, and nobody called me to be at their deliveries. I was only informed after the babies were born, when postpartum orders and newborn orders needed to be put in! This was infuriating, because I loved OB.
I came to the morning sign-out, almost crying. My senior resident saw my face, and knew something was wrong. “Zed, what’s going on?” He pulled me aside and asked me. I started crying, and said I spent all night running around, didn’t even visit my call room one time, and ended up missing all the deliveries, because no one called me. “I will take care of that. Just go and sign out to the day team.” He said. So I did.
Later on, I got an apology page from the OB floor. I found out that my senior resident went to the OB floor to have a talk with both the nursing staff and the delivering attending, telling them how devastated I was, and how this was not right. I went on to have a very friendly relationship with the OB floor, who never let me miss another delivery for the remainder of my training. (Eric, thank you for being so awesome!)
That, is the story you want to hear as an interviewee. (I have a few examples of when the faculty stood up for me, too; and later on, I stood up for my own interns.)
How many women/minority faculty are there?
This is an important question regardless of your gender and ethnic background, but especially important if you don’t fit in the cis-gendered, straight, white male demographic. Are there people in the faculty who understand who you are and where you are from on a deeper level? Of course, just because the answer might be yes, doesn’t mean that they would be your best advocate. After all, not all women are feminists, and everyone has their own social ladder to climb. But as a resident, especially an intern, you are at a vulnerable stage of your professional career on so many levels. Your toughness and resilience will be tested. And you will want to find comfort and seek advice from those who have come before you, travelled the same path as you, or even paved the roads for you.
Do you rank local applicants higher?
A residency should be diverse, even if the local population isn’t. It’s important to expose both future clinicians and patients to folks who don’t look like ourselves. I hope I don’t need to further explain why this is. If you want to stay close to home, and therefore match into a local residency program, that is a perfectly fine choice. However, most medical graduates move out of states for training, and they should be able to feel included. Ultimately, if you are planning to go out of state for a residency, and you sense that the residency favors local candidates, you might be in for a very long 3+ years.
If my mental health was affected negatively by residency training, what are some ways you could support me?
In medicine, there is a weird tradition to shame those who struggle with their mental health. “They are not strong enough”, or “they aren’t cut out for this”, or “it’s normal to feel this way, so don’t complain.” The newer generation medical trainees are much more open about their mental health, as more and more physicians “come out” as regular human beings on antidepressants, or in therapy. So that is a good trend.
But if you do struggle, which you will, you need to make sure the residency you choose to go to normalizes having mental health issues, offer mental health days, and doesn’t “punish” those who are having a hard time. Beware that sometimes, punishments can disguise as “mental health help”, such as making a resident “split a year” or delay graduation against their will in circumstances like this.
Don’t settle for vague answers to this question. Look for concrete mechanisms in place by the residency to help a struggling resident, who is all of us.
Are people honest in reporting work hours?
There are several rules required by the ACGME for medical resident work hour restrictions. Most of the requirements are an average over 4 weeks. For example, the 80-hour-week limit is an average number. This means on the week you put in 120 hours (lots of OB continuity deliveries, etc), you should be given time off the following weeks to balance it off. The residency is responsible for keeping track of how much their residents are working, and there should be a reporting system that can’t be edited after submission for this purpose.
Ask the residents if there is pressure from the program to under-report work hours. If so, run.
Would I become competent in the specific area I am interested in?
You might already know what you plan to do after graduating from residency. In my case, I wanted to go rural, and wanted to maintain an OB practice. So I needed to make sure I would be competent in delivering babies and managing labors and obstetric emergencies. Preferably, I would like to do so without having to go for additional fellowship training. So it was important for me to ask the average number of OB continuity deliveries for the residents.
It’s always important to ask about pediatrics, especially inpatient pediatrics. Sick kids and sick adults behave very differently, their dosage of medications are different, and very different things cause their garden variety illnesses. Across the board, FM residencies are struggling with their pediatric case numbers. If the residency of your choice doesn’t offer inpatient pediatric rotation, or PICU rotation, and these are important for you, make sure you ask if they offer away rotations for these crucial clinical skills.
Other areas that might be of importance for you are: inpatient hospital care (if you are interested in becoming a hospitalist), office-based procedures including casting (if you want to do urgent care), LGBTQ+ care, nursing home, hospice, and sports medicine.
If I needed coverage for my shift, do others usual volunteer to cover me?
Comradery is a choice. Does the residency choose to cultivate a supportive environment for coverage? Ask the residents if they are responsible for finding their own coverage when they need time off, or does the chief resident/faculty simply say “go do what you need to do, don’t worry about your shift”? How often does a resident have to forgo important event in their lives (funerals, deaths, marriage, procedures, etc.) because they couldn’t find coverage for their shifts? Trust me, 10 years later, you will still remember the colleague who stepped up when you were in need. And if there were several co-residents who were willing to step up for you, it would leave a forever warm and fuzzy feeling in your heart when you recall the most challenging period of your training. That is a gratitude you will carry on with you for the remainder of your career.
Residency is a physically and emotionally exhausting time of a physician’s life, and it can be so unforgiving. Choose carefully who will become your mentors, in front of whom you will make the dumbest mistakes of your career, and whose literal shoulders you will cry on when you are the most vulnerable. The culture of medical education is passed on through you, and it matters tremendously what type of influence your residency has on you. Will you graduate to become a strong advocate for your residency? Will you grow up to be the kind of attending you’ve admired during your training? Will you become a good teacher because your senior resident was a good teacher? And more importantly, can you take pride in the training you received as a resident, like how your residency does in the physician you will become?
