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After the Match

After the Match: Sticks and Carrots and Residents

Cook, Thomas MD

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doi: 10.1097/01.EEM.0000455718.92255.c9

    I wrestled for years with ways to get residents to complete required tasks. I used traditional strategies. I yelled at them. I bullied them. All those failed. I even had one resident wait three years after graduation before he turned in his scholarly project to sit for the boards.

    I thought about it, searching for something that residents could not ignore. It turns out that something is time. They hate losing it. When we were trying to schedule months with equal amounts of shift work, trying to penalize them with more hours did not produce the desired effect. They knew they were being penalized on certain shifts because they knew they were working more that month compared with their classmates. That made them resent being there. It was not fun for them, the attendings, their peers, and probably not so great for the patients either.

    But the Hours Bank, as I explained last month, allows hours to fluctuate from one resident to the next every month, all for a variety of reasons. Residents receive a monthly statement that shows the number of hours they have worked since the beginning of residency and the number of hours needed to graduate. Any penalties handed out add time to this number. Now residents cannot earmark a specific shift as a penalty. Instead they see the number of hours they need to graduate going up instead of down. Other residents not only see who is being penalized, but why, and most importantly, how far behind they are compared with their classmates. Interns see this happening to upper level residents (including chiefs), and they quickly realize they do not want it to happen to them. So that's the stick, but where is the carrot?

    We also give out awards. A resident who does something special for the program, their peers, or a patient is awarded hours of credit in the Hours Bank. They know they are giving up their time when they volunteer for a committee, come in for a resident who is sick, help with high school athlete physicals, work at a local health fair, and pay to travel to another country for a two-week health mission, but they also know they get some of it back. The time put into these volunteer activities usually exceeds the hours awarded, but the award is intoxicating enough to prompt the residents to do it and to open their minds to activities related to hospital, community, and professional service. It also fosters our program's reputation of volunteerism and as the place for our hospital to go when they need to get something done. Only two residents have graduated with more penalty hours than awards over the past three years.

    I know other program directors will see problems with this. What if a resident volunteers for so many activities that he spends too few hours working in the ED? Our average balance of award to penalty hours per graduating resident is plus-90. This is about a two percent reduction in the total amount of time they would have worked without this incentive program. One resident actually managed to amass a total of 287 hours (6.5%) of award time. He also spent eight weeks working on medical missions in Samoa, Guatemala, and Tonga. He ended up working more clinical hours, saw more patients, and got an incredible education in the process.

    Another criticism is that underperforming residents should not have the privilege of seeing more patients. This might make some sense in a utopian world, but my primary responsibility is to make residents understand how to be successful. This requires that I strike a balance of making them accountable for their actions as a professional while pushing them through the doors of opportunity. The Hours Bank does just that. It makes shirking responsibilities unpalatable while encouraging the discovery of other areas of health care and professionalism.

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    ‘Bribing’ Residents

    Listen to the Freakonomics podcast, “Why You Should Bribe Your Kids” to hear more about the basis for the Hours Bank at

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