Changing of the Guards: The Pearls and Perils of Shifting Expectations in Residency Training.

The intern rattled off the fruits of her prerounding labors. The senior supervisor listened closely, unsurprised that the intern had not missed a single detail. She was rounding the corner from the objective data to her assessment when the nephrology attending physician interjected, “and the urine output?” The intern hesitated, then confidently responded, “Over the last 24 hours his urine output was 1.3 milliliters per kilogram per hour.” To her surprise, the attending said, “As I tell all of your colleagues when they come through this rotation, I prefer that you present the patient's fluid balance rather than the urine output in milliliters per kilogram per hour.” The intern nodded politely and moved on to the assessment and plan. It was her first day on this rotation, one in which she cared for patients on a variety of subspecialty services. Returning to the workroom, she resolved to be more prepared the next day.

The following morning, she arrived to rounds with a hematology attending physician with her new urine output calculation. Once again, the intern gave a flawless presentation, this time citing the fluid balance over the last 24 hours. She began her assessment when the attending physician interrupted her, stating, “I'm sorry, but I have no idea what to think about the fluid balance that you just reported. Do you have it in milliliters per kilogram per hour?”

It is easy to make assumptions about what makes it difficult to be a resident. While many aspects of residency are demanding, we believe that one of the most challenging and least noted parts of our job is the constant change. With each new rotation, residents across specialties and postgraduate years take part in an almost ritualized “changing of the guards.” Just as residents finally master the nuances of one rotation, they have to gather their belongings, prepare a handoff for the colleague who will be taking their place, and venture to new and unfamiliar locations in the hospital or outpatient setting. With each change in rotation, there is not only a change in the patient population, but also a distinct change in personalities, protocols, and expectations. In a single year, a resident is forced to feel the anxiety that comes with starting a new job on 12 or more distinct occasions.1 Furthermore, within a single monthlong rotation, a resident's supervisor may change multiple times, and during a single day a resident will often interact with multiple bedside nurses, case managers, social workers, and other members of an interdisciplinary team. Frequent changes between rotations have been shown to be associated with resident stress, negative coping strategies, and a perceived negative impact on patient care.1

How is a resident to succeed amid ever-changing expectations? In this article, we suggest strategies to address frequent transitions and shifting expectations in residency that focus on the individual behaviors of the resident, attending physician, residency program, and the interactions among these groups. We believe that utilizing these strategies could help ease the burden of frequently changing expectations and contribute to the professional growth of residents and attending physicians. Additionally, we describe system-based interventions at the level of the training program, which optimize the learning experience for residents who face ever-changing roles. These solutions are summarized in the Table.

Table

Resident, Attending, and System Strategies to Address Frequent Transitions and Shifting Expectations in Residency

Resident	Attending Physician	System (Program)
Resident strategy Embrace discomfort Adapt to differing expectations	Attending strategy Be flexible Model adaptability Empathize with resident experience	Program strategy Perform cyclical rotation review Trial innovative training models Integrate feedback
Resident-driven interaction with attending Seek expectations (and rationale of expectations) Frame prior experiences Share strengths and challenges Build relationships	Attending-driven interaction with resident Set early expectations Promote adaptability Provide feedback on transition Build relationships	Program-driven interaction with resident Provide resident development (eg, adaptability curricula) Frequent “check-ins” with residents regarding rotation shifts/transitions
Resident-driven program improvement Provide feedback on rotation dynamic Report barriers to smooth transition	Attending-driven program improvement Provide feedback on rotation dynamic Report barriers to smooth transition	Program-driven interaction with attending Frame learner's journey Provide faculty development (eg, expectation setting)

At the most basic level, residents should become accustomed to seeking expectations when encountering new supervisors,1 and supervisors should become accustomed to clearly delineating their expectations to new learners.2,3 Even with clear expectations, resident success is not guaranteed unless the resident can satisfy expectations. To do so, trainees and programs should recognize adaptability as a crucial trait that can be cultivated and even screened for in residency interviews.1,4,5 The adaptable resident is one who shows up each month, weathers the initial storm that comes with an inevitable shift in expectations, and then flourishes rapidly in this new setting. While some residents may spend the entire month merely discerning what is expected of them before being whisked off to a new service, other residents find quick success in meeting the needs of an inevitably moving target. These residents embrace the discomfort of starting a new rotation, adapt to new approaches and styles6 while trying to understand the rationale behind them, seek real-time feedback,7 reflect on their performance, act on the feedback they receive,8 anticipate and become accustomed to varying rounding and presenting styles, and at the end of the rotation, share their perspectives with the program, their attending physician, and their colleagues. At the start of a new rotation, residents should frame their prior failures and successes with a new supervisor. Cognitive flexibility9 in the face of constantly shifting rotations could also help to improve resident performance, job satisfaction, empathy, and resilience.10–12

Additionally, attending physicians may learn to be flexible. Flexible attending physicians understand the challenges that residents face trying to meet the varying expectations of different supervisors.2 Therefore, they set clear expectations at the beginning of a learning experience and might even establish a supervision contract with the resident.2,3,13 They also allow for flexibility in their expectations.14 For example, if a resident has learned an effective way of presenting on rounds that differs slightly from a specific attending physician's preferred way, the attending physician may allow the resident to proceed. Attending physicians also should work to foster the behaviors of successful residents, like seeking and acting on feedback.14 As products of the same medical education system, attending physicians are themselves “adaptive experts”15 and can use their experience to teach residents the necessary skills for developing this adaptive proficiency.16

The residency program must also do its part to ensure that trainees are prepared to meet its shifting demands. For example, attention to rotation structure, call schedule, and rotation length may maximize the time a resident spends with a given attending physician. Longitudinal integrated clerkships have become a popular solution for medical students17 and are being trialed in graduate medical education, although mostly in ambulatory settings.18 Even within traditional rotation structures, there are opportunities to promote relatedness (the need to feel connected with others and valued by one's community)19 among team members,20 because promoting positive relationships has been shown to be an important factor in mitigating the stress of transitions.1 Additionally, current work evaluating the validity of assessment tools for pediatric residency rotations21 could be expanded to include questions about rotation transitions. Residency programs should work to acquire and integrate resident and faculty feedback pertaining to frequent rotation transitions,22 support and cultivate an environment of adaptation15 and flexibility, and provide residents and faculty with specific curricula on topics such as expectation seeking and setting, adaptability, flexibility, and feedback seeking and delivery.12,23

By the end of the intern's block, she knew how to report the ins and outs to each attending physician. But perhaps more importantly she understood the rationale behind the different expectations. Going forward she strategized how she would approach her next rotation and imagined how to set expectations with her trainees as an attending physician in the future. While the monthly changing of the guard ritual embodies one of the most difficult aspects of a resident's job, we believe it is also essential to their growth, success, and education as trainees.6