22,476 residents responded to at least one item on the optional survey (19% of the total resident population), and of those respondents, 1,782 residents (7.9%) offered open-ended comments. As shown in Tables 1 and 2, these comments were made by a diverse group of residents. While a small sample, it closely followed the proportions of the total resident population for 2013; all medical specialties and some subspecialties were represented. 50.4% (n = 898) of the comments were made by males, and 46.5% (n = 829) of the comments were made by females. With respect to PGY year, there were 24.0% (n = 428) PGY1s, 21.9% (n = 391) PGY2s, 24.6% (n = 439) PGY3s, 12.0% (n = 214) PGY4, 4.7% (n = 83) PGY5, 1.5% (n = 26) PGY6, 0.5% (n = 9) PGY7, and 10.8% (192) fellow. 65. 3% (1164) were graduates of American allopathic medical schools (AMG), 9.7% (172) were graduates of Osteopathic medicine programs (DO), and 25.0% (446) were graduates of international medical schools (IMG).
The residents’ comments ranged from phrases to several paragraphs and covered almost every aspect of daily and professional life. The variety of individual issues raised spanned scheduling and “scut” work, personal interactions and relationships, and educational and professional incidents and opportunities. Through iterative coding, we identified six concerns that captured 50% of the comments. In addition to duty hour requirements, we identified five recurring themes: children at home, satisfaction with their program, unprofessional behaviors/mistreatment, slavery, and debt (see Table 3 for the full list of themes and representative quotes). Many comments included multiple themes. The coders determined that 12.4% of the comments had an overall positive tone and 60.9% had an overall negative tone. Below we describe the themes and provide quotes for each theme.
Table 1. Demographic information of survey respondents who entered comments alongside residents and fellows.
|
Survey respondents who offered comments
|
All Residents and Fellows in Academic Year 2012-2013*
|
Gender
|
N
|
Proportion
|
N
|
Proportion
|
Female
|
829
|
46.5%
|
51,262
|
43.5%
|
Male
|
898
|
50.4%
|
59,990
|
51.0%
|
Refused/Missing
|
55
|
3.1%
|
6,465
|
5.5%
|
Undergraduate Medical Education Category
|
N
|
Proportion
|
N
|
Proportion
|
US/Canadian Allopathic Graduates
|
1,164
|
65.3%
|
76,543
|
66.7%
|
Osteopathic Graduates
|
172
|
9.7%
|
9,536
|
8.1%
|
International Medical Education Graduates
|
446
|
25.0%
|
31,380
|
26.7%
|
Mean Age
|
31.9
|
30.7
|
Totals
|
1,782
|
117,717
|
*ACGME Data Resource Book: Academic Year 2012-2013. ACGME Department of Applications and Data Analysis. https://www.acgme.org/Portals/0/PFAssets/PublicationsBooks/2012-2013_ACGME_DATABOOK_DOCUMENT_Final.pdf (last accessed February 10, 2020).
Table 2. Self-reported specialties and training levels of residents and fellows who offered comments.
Self-reported Specialty
|
Self-Reported Training Level
|
Total
|
Proportion of Commenters
|
PGY1
|
PGY2
|
PGY3
|
PGY4
|
PGY5
|
Internal medicine
|
130
|
102
|
120
|
.
|
.
|
352
|
19.8%
|
Family Medicine
|
77
|
62
|
74
|
.
|
.
|
213
|
12.0%
|
Pediatrics
|
46
|
52
|
57
|
.
|
.
|
155
|
8.7%
|
Psychiatry
|
32
|
24
|
22
|
29
|
.
|
107
|
6.0%
|
General Surgery
|
28
|
23
|
23
|
12
|
13
|
99
|
5.6%
|
Emergency Medicine
|
25
|
22
|
21
|
3
|
.
|
71
|
4.0%
|
Anesthesiology
|
6
|
21
|
20
|
20
|
.
|
67
|
3.8%
|
Radiology
|
.
|
12
|
13
|
25
|
14
|
64
|
3.6%
|
Obstetrics/Gynecology
|
11
|
13
|
11
|
17
|
.
|
52
|
2.9%
|
Pathology
|
16
|
10
|
11
|
6
|
.
|
43
|
2.4%
|
Internal medicine/Pediatrics
|
9
|
8
|
15
|
15
|
.
|
47
|
2.6%
|
Neurology
|
.
|
11
|
13
|
12
|
.
|
36
|
2.0%
|
Other Specialties and Fellowship Programs
|
.
|
.
|
.
|
.
|
.
|
476
|
26.7%
|
Table 3
Themes and Representative Quotes from resident comments
Children at Home (n = 13.5%) | Satisfaction with their Program (9%) | Unprofessional Behaviors/ Mistreatment (8%) | Slavery (4%) | Financial Pressures (3%) | Duty Hours (?%) |
I hate residency. I would not likely do it again. If I did, I would not do it here. I have been lied to, yelled at, belittled, penalized, and shunned because I am a mother with children. | Residency, although exhausting, is amazing. If I had to do it again, I would do everything exactly the same. | My father passed away and the chief resident at that time stated if I wanted time off I should have planned in advance. | I came to the United States to have [an] education…not work as a slave. | I probably would not choose this profession if I had it to do over again…I feel stuck because I'm > 250K in debt and can't quit… | The duty hour restrictions for interns are fantastic - it makes it very bearable, giving me time to study and to see my family. |
Having a spouse and child outside of residency is extremely difficult…I do not have enough time to make my spouse and child happy. The process creates family problems that I just hope we can make it through… | Doing residency is not easy, it has its down moments, hours, days. But the up moments certainly remind me why I have chosen this profession. | The atmosphere of fear and intimidation is so strong, you feel powerless to do anything to help try and change it. And thus the cycle of abuse continues. | Residents, in general, are indentured servants who are treated like slaves with the elusive carrot stick at the end of the training that may or may not exist. | If I could walk away without my quarter million dollars’ worth of debt I would gladly give up the last ten years of my life to get out of medicine. | I think the new work hour restrictions…are adding additional burden and stress…the combined new experiences lead to increased depression, anxiety, and medical errors. |
Residency is currently complicated by major life events including a 7 month old son with a significant congenital abnormality. I have received little personal support and time to address his issues. | This is my second residency; I left my previous residency because of "hazing" and extreme scheduled duty hour violations. Last residency was horrific–current residency is just about perfect. | Staff are rude, condescending, unprofessional, and frankly act in a manner which borders on true workplace harassment (call outs for stupidity, fatness, being "too" ethical…) | I also feel very disappointed with being treated like a slave, spending hours of time each week doing inane administrative work that takes away from time to read and study and become a smarter, better surgeon. | Internal Medicine residency is an indentured servitude. We spend 7 years in training and accumulate an enormous financial debt. We are locked into non-negotiable contracts and are completely dependent on the recommendations of our superiors. | Almost all the trainees I know, do not log their entire duty hours because of “fear of losing accreditation" constantly held up by faculty. |
Theme 1: Children at Home
A number of residents commented about having children at home, an emergent issue with ever-increasing numbers of women entering residency and lengthening in the average duration of training.11,12,13 Approximately 13.5% (n = 240) of the comments made mention of the experience of having children at home (25.0% were from males, 74.2% were females). Several residents attributed the fatigue reported on their survey to childcare responsibilities after work, and not due to the duties required of their programs. For example, this resident wrote, “I have two kids and that is probably most of my fatigue” (PGY5, Radiation Oncology, Male, AMG). Others expressed strong feelings about balancing training with the demands of parenthood, struggling to excel in both roles. “I also have 2 kids which contributes to sleepiness and stress, as well as inadequacy at home and at work. There is never enough time…feeling like I am both a bad doctor and a bad mother.” (PGY2, Pediatrics, Female, AMG). Another wrote “…residency training is poorly compatible with raising a child, and I’m not convinced it’s good for child or parent (we have an 18-month old son and my wife is also a resident now)” (PGY1, Preventive Medicine, Male, AMG). Another wrote about the tradeoff that women in medicine must make with respect to family.
“I think the biggest impact on life that is not given enough attention is [the] opportunity for having children. Our current training pathway is not at all conducive to having a family, and many women end up delaying it. I waited until fellowship and am now having kids 15 months apart to make up for it…There has to be serious daycare cost relief for residents and fellows whose salaries can hardly cover the cost of childcare for all the hours they are at work plus rent, not to mention food…we are subject to inhumane rules about coming back to work after childbirth.” (Fellowship, Internal Medicine, female, AMG).
Theme 2: Satisfaction with their program
While many comments were negative in tone, 9.3% (165) of the residents relayed positive observations about their programs. A majority of these positive comments were vague, with residents reporting that their programs were “a wonderful experience” (PGY2, Anesthesiology, female, IMG) or “a great learning environment,” (PGY1, Internal Medicine, male, AMG). Most comments did not identify the aspects of their programs that made their experiences enjoyable. Some positive comments were encouraging, however, suggesting that certain programs have created excellent training environments: “I love my program. It is a great program, great faculty, great residents. Strong learning environment. I have plenty of free time and great work/free time balance.” (PGY2, Anesthesiology, male, AMG). Another comment, from a resident who had switched programs, showed that it is possible to find a training environment with the right fit for a particular resident; “Last residency was horrific- current residency is just about perfect.” (PGY1, Internal Medicine, female, AMG). One resident described how her program was able to accommodate her in the face of illness:
“I was diagnosed with rheumatoid arthritis during my training and my program has been amazingly supportive in helping me deal with the illness. I work a 2 week on 2 week off schedule now to help me deal with sleep deprivation, fatigue and painful flares. Very supportive residency program.” (PGY3, Internal Medicine, female, AMG).
Theme 3: Unprofessional Behaviors/Mistreatment
We also identified a theme of unprofessional behaviors and mistreatment. 8.9% (159) of residents (53.5% male, 38.4% female) recounted stories about forms of mistreatment or unprofessional behaviors. Several residents found a pervasive culture of abuse and mistreatment in their program, writing: “In no other field can I imagine a climate in which bullying is felt to be a rite of passage and trainees are penalized for voicing concerns.” (PGY4, Endocrinology, female, AMG). One resident described the toll that a particularly toxic work environment placed not only on her enjoyment of her work, but also on her personal health:
“When one is constantly picked on by those in power it becomes hard to enjoy work. I do well with patients and families, something even my critics agree, I have a good fund of knowledge and am competent…I love pediatrics, I love working with patients, and I have truly learned a great deal… I cannot continue to take the personal persecution that is allowed in our program and that targets 1–2 residents a year. It is actually criminal, and there is no recourse, because one simply must endure or quit. (PGY3, Pediatrics, female, AMG).
Others felt that the culture of medicine as a whole contributed to their feelings of mistreatment. “In fact, if this workplace were replicated in any other sector (business, law, etc.) the behaviors that my fellow residents are subjected to would be easily grounds for termination of our superiors due to intimidation, unprofessionalism, harassment.” (PGY4, General Surgery, male, AMG).
Theme 4: Slavery
The term “slavery” along with another related term of “indentured servitude” were used by approximately 4% (n = 71) of the residents who provided comments; this theme was represented by a perceived lack of control surrounding training, coupled with outside pressures such as debt and time already spent. One resident described his frustration with his position as a resident:
“I resent that I am little more than an indentured servant who is forced to spend as few minutes as possible with my patients so that I can care for an overwhelming number of people who deserve better care than I am able to provide.” (PGY3, OB-GYN, male, AMG).
Another simply wrote “Residency is slavery.” (PGY3, Emergency Medicine, female, IMG). A different resident summed up his feelings about training and need for better working conditions, by making this statement: “Since I started my residency I feel residency programs treat resident[s] like they are machines. It needs to change.” (PGY1, Internal Medicine, female, IMG).
Theme 5: Financial Pressures
Finally, about 2.8% (50) of residents commented on their concerns with the debts that were accruing during their training.
“It is a matter of some concern for me when I think of the financial burden on the residents. They have either student loans to take care of, or a family to take care of, or both…With a paycheck that barely stretches from month to month it becomes stressful to consider this pattern staying with one for a period of 3–4 years” (PGY3, Psychiatry, female, IMG).
The preceding comments underscore the depth of the financial pressures that residents feel after leaving medical school and their impact on the residents’ feelings about the profession. Interestingly, while some residents worried about what their debts meant for the future: “I am very fearful that I will not be able to make enough money once I complete residency to pay off my loans and live comfortably without being overworked and overwhelmed.” (PGY3, Psychiatry, male, AMG), others reported more immediate and daily levels of concern for their financial situation: “When I'm not stressed about work-related issues, I'm stressed over money-related issues. Greater attention needs to be given towards educating residents about finance.” (PGY4, Pathology, female, AMG). One resident strongly felt that the debt was hurting the medical profession, stating that “no one wants to do primary care because of [debt] and less and less people are going to want to go to medical school because of it.” (PGY3, Radiology, male, DO). The financial pressures on residents contribute to worry across several domains, including day-to-day concerns, future financial stability, and the medical profession as a whole.
Theme 6: Duty Hours
Throughout the comments, about 13% (232) of residents made some mention of duty hours. The comments about duty hours tended to be polarized with some viewing the changes as positive, allowing for a better work-life balance. For example, this resident acknowledged that “I probably have better quality of life than if I had no work-hour restrictions.” (PGY1, Emergency Medicine, female, AMG). On the other hand, many comments were quite critical of the duty hour changes implemented, such as this one: “The work-duty hour limitations continue to put excessive stress on medical programs and dilutes the residency experience. It seems that training is ultimately affected in a negative manner, as much of the work is becoming shift work.” (PGY3, Urology male, AMG). Of note, the issue of duty hour requirements is currently undergoing extensive research, and therefore will not be the focus of our analysis in this manuscript.14,15,16
Demographic Variation of Comments
While the demographic data of trainees who commented resemble those from the ACGME data-book for 117,717 residents and fellows (See Table 1), there were some interesting variations as it related to specific concerns. Firstly, concerns about children at home increased each year (from 12.1% for PGY1 to 24.6% by PGY3), and were expressed by more women than men (74.2% vs. 25.0%). Also, concerns about mistreatment were more frequently expressed by men (53.5% vs. 38.4%) and by international medical graduates (35.2% of the comments vs. 25.0% of total residents and fellows in the ACGME data-book). Issues of financial pressures and “slavery” were also raised more by males than females, and financial pressures were of much greater concern for graduates of US allopathic medical schools versus graduates of osteopathic or international medical schools. Finally, comments on program satisfaction closely followed the demographic profile of the overall resident and fellow population.
Table 4
, Demographic Variation in Comments
| Children at Home | Satisfaction with their Programs | Unprofessional Behaviors/ Mistreatment | Slavery | Financial Pressure | Duty Hours |
N | 240 | 165 | 159 | 71 | 50 | 232 |
Variable | | | | | | |
Med School | | | | | | |
AMG | 185 | 95 | 85 | 43 | 39 | 174 |
AMG% | 77.1% | 57.6% | 53.5% | 60.6% | 78.0% | 75.0% |
DO | 24 | 14 | 18 | 12 | 7 | 21 |
DO% | 10.0% | 8.5% | 11.3% | 16.9% | 14.0% | 9.1% |
IMG | 31 | 56 | 56 | 16 | 4 | 37 |
IMG% | 12.9% | 33.9% | 35.2% | 22.5% | 8.0% | 15.9% |
Sex | | | | | | |
Male | 60 | 88 | 85 | 43 | 30 | 142 |
Male% | 25.0% | 53.3% | 53.5% | 60.6% | 60.0% | 61.2% |
Female | 178 | 75 | 61 | 23 | 16 | 85 |
Female% | 74.2% | 45.5% | 38.4% | 32.4% | 32.0% | 36.6% |
Specialty | | | | | | |
IM | 24 | 43 | 39 | 15 | 5 | 68 |
IM% | 10.0% | 26.1% | 24.5% | 21.1% | 10.0% | 29.3% |
FM | 8 | 8 | 9 | 5 | 3 | 8 |
FM% | 3.3% | 4.8% | 5.7% | 7.0% | 6.0% | 3.4% |
Peds | 29 | 11 | 6 | 3 | 1 | 23 |
Peds% | 12.1% | 6.7% | 3.8% | 4.2% | 2.0% | 9.9% |
Psych | 23 | 11 | 10 | 3 | 6 | 8 |
Psych% | 9.6% | 6.7% | 6.3% | 4.2% | 12.0% | 3.4% |
Gen Surgery | 4 | 11 | 12 | 3 | 3 | 22 |
Gen Surgery% | 1.7% | 6.7% | 7.5% | 4.2% | 6.0% | 9.5% |
ER | 8 | 8 | 9 | 5 | 0 | 8 |
ER% | 3.3% | 4.8% | 5.7% | 7.0% | 0.0% | 3.4% |
Anesth | 8 | 8 | 8 | 5 | 7 | 2 |
Anesth% | 3.3% | 4.8% | 5.0% | 7.0% | 14.0% | 0.9% |
Radiology | 19 | 4 | 5 | 0 | 2 | 10 |
Radiology% | 7.9% | 2.4% | 3.1% | 0.0% | 4.0% | 4.3% |
Pathology | 10 | 1 | 4 | 1 | 6 | 3 |
Pathology% | 4.2% | 0.6% | 2.5% | 1.4% | 12.0% | 1.3% |
OB-GYN | 12 | 1 | 1 | 1 | 1 | 5 |
OB-GYN% | 5.0% | 0.6% | 0.6% | 1.4% | 2.0% | 2.2% |
Others | 95 | 59 | 56 | 30 | 16 | 75 |
Others% | 39.6% | 35.8% | 35.2% | 42.3% | 32.0% | 32.3% |
PGY | | | | | | |
PGY1 | 29 | 63 | 27 | 20 | 8 | 48 |
PGY1% | 12.1% | 38.2% | 17.0% | 28.2% | 16.0% | 20.7% |
PGY2 | 40 | 38 | 36 | 16 | 15 | 53 |
PGY2% | 16.7% | 23.0% | 22.6% | 22.5% | 30.0% | 22.8% |
PGY3 | 59 | 39 | 47 | 15 | 9 | 67 |
PGY3% | 24.6% | 23.6% | 29.6% | 21.1% | 18.0% | 28.9% |
PGY4 | 40 | 11 | 21 | 5 | 6 | 30 |
PGY4% | 16.7% | 6.7% | 13.2% | 7.0% | 12.0% | 12.9% |
PGY5+/Fellow | 72 | 14 | 28 | 15 | 12 | 34 |
PGY5+/Fellow% | 30.0% | 8.5% | 17.6% | 21.1% | 24.0% | 14.7% |