It was early June and time for final evaluations. One senior resident (actually a composite of many similar residents I have had) had worked extremely hard to live up to the high expectations of our staff, his family, and, most importantly, himself. When we reviewed his faculty and peer evaluations and performance data in the past, he had always become upset by relatively small criticisms. This day, however, was different.
He had inked a deal with a great group in the city where he had always dreamed of practicing, and this triggered a wave of relief from knowing that the academic and professional gauntlets he had maneuvered since high school were finally over. He began counting down his shifts, and bought a house in the city where he would be working. He took a week's vacation in May to move into his new home, and when he returned, he became more frustrated with recidivist ED patients and sloppier with his checkouts. He also started taking shortcuts on patient evaluations, and stopped getting full histories and complete exams.
The comments from the faculty and his peers in his last evaluation, however, didn't mention the decline in his work habits. Instead, they said: “Great to have you here for the past three years.” “We'll miss you.” “Good luck in your new job.”
The candor was gone. It's understandable. Why would an attending or a peer criticize someone halfway out the door? They think the resident is not really listening to advice anymore and will rationalize anything he does not want to hear. Besides, it's not unusual to think that he will leave bitter and resentful if criticized on his final evaluation.
Then we looked over his procedure log. He had not met several of the benchmarks set by the Residency Review Committee. One deficiency was splinting. He said he was too busy to take the time for this, so he let the cast tech do it. “Besides, there really aren't that many fractures that come into our emergency department.” (Our annual census is more than 92,000, including 4,000 fractures each year.) As for the other procedure deficiencies, he said he was too busy to enter these into his log. I reviewed his off-service rotation evaluations and noticed that he did not have one for his elective in March. “I had a bad viral infection at the beginning of the month,” he explained, “so I spent most of the time getting better.”
All of these are classic symptoms of senioritis, where a resident disengages from residency too early.
A Common Flaw
You might think this is hyperbole or points to the fact that I have lazy residents and run a slack program. All of my stories are true, though this one is a composite of residents from the past 17 years. Senioritis happens, but not because my residents are lazy. They are the best people I know. They are human, however, and a certain percentage will disengage from residency too soon. It also happens with folks graduating from high school, college, and medical school. It happens when someone leaves one job for another, and it happens when someone approaches that magical day of retirement. This is what humans do as they approach the end of any commitment. They slow down and off-load the effort and anxiety of holding themselves accountable.
The challenge is understanding that this will happen every year. It's difficult for many of us to anticipate these human flaws in such extraordinary overachievers. They are doctors because they avoid this behavior. But any seasoned program director will tell you that a certain percentage of each residency class will phone it in as graduation approaches. I even had one pending graduate go on a cruise and skip graduation instead of staying in town for one more week.
My remedy for senioritis proved to be relatively simple (but it took me a long time to figure it out). I moved up the due date for their nonclinical assignments. Our benchmarks for procedures, ultrasounds, scholarly projects, and anything else I can think of are now Jan. 1, not the end of June. If a resident misses the mark, I still have a way to incentivize him by giving him additional clinical opportunities to excel and by restricting moonlighting privileges. Nothing motivates residents like the threat of more shifts and less money.
This isn't really nice, but it's a lot better than having an uncomfortable conversation in June about how graduation must be delayed because the ACGME requirements were not completed. One resident finally sent me his project three years after he graduated so he could sit for the boards. I guess he figured I would let it go. (I didn't.)
Give it a little thought if you think you are coming down with this common ailment. Many residents have been distracted by the excitement of what happens after graduation. But most people remember the last experience they had with you. You will not want the great group of people you shared this incredible experience with to remember you as someone who emotionally left town before he should have.
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