Dear Colleague,

In May 2006, the American Medical Association (AMA) embarked on its second annual Member Connect^® survey of the Resident and Fellow Section (RFS). This survey included more than 650 respondents who answered questions about 4 key issues that have surfaced among RFS members.¹ These key issues include intimidation in residency, care for the uninsured, student debt, and medical liability reform.

Intimidation in residency is a relatively new issue, and many residents surveyed believe this has surfaced as a result of the limitations in resident work hours and the pressure for training programs to comply with the new Accreditation Council for Graduate Medical Education (ACGME) work-hour standards.

More than 75% of residents surveyed think that intimidation in residency is a serious issue and should be addressed. Of residents who have experienced intimidation, one fourth have had threats of nonphysical harm, and almost another one fourth have been pressured to report work hours inaccurately.

Senior residents and attending physicians are the most frequent perpetrators of intimidation. Nearly 70% of residents reported that they would not know how to report intimidation.

Although intimidation in the resident work environment is a new concern for our membership, it is not a new phenomenon. Intimidation in medical training has been present for several decades, and some would argue that it has been present for as long as formal specialty training has existed. For the most part it is not worse now than in decades past; rather, the learning environment has changed. Formal medical education dates back several centuries, but organized training is thought to have begun at the turn of the twentieth century with Sir William Osler, the “father of medical education,” and William Stewart Halstead, the “father of American surgery.”^2,3

Initially, structured training involved an intense devotion to the field of medicine. Most programs were sleep-in residencies that were open-ended and had a long tenure. Residents led a monastic lifestyle, and programs were pyramidal—only a few select residents ever succeeded at completing training. Such training created extraordinary expectations for trainees, where criticism and intimidation were commonplace.^3-5

In the early years, specialty training was very nonstandardized and involved great variations in quality and in length of training. As a result, several groups, including the AMA, became involved in trying to help standardize graduate education. In 1914, the Council of Medical Education and Hospitals created a list of hospitals approved for internship. By 1928, the AMA House of Delegates had published the “Essentials of Approved Residencies and Fellowships,” which set early standards for residency programs. In 1953, the Residency Review Committee was developed. In 1981, the ACGME was founded. There are now 26 residency review committees, 1 transitional year review committee, and 1 institutional review committee within the ACGME.⁵

Over the past century, the trend has been the standardization and increased regulation of graduate medical education. Faculty and training programs have been required to meet a growing number of training requirements and mandates. And, although most would agree that these mandates are beneficial to graduate training, a certain resistance exists on the part of senior educators to adapt their training styles. This leads to a conflict between trainer and trainee, and one of the products of this conflict is intimidation.

To better understand this educational conflict today, we must examine some key principles central to the structure of a trainer–trainee relationship. First and foremost it is essential to understand how the trainer (or faculty) learned to teach. Most faculty are never trained in medical education. These people are physicians, not educators. As a result, they use the only form of education they are familiar with—they teach the same way they were taught.

And because of the number of years invested in becoming a physician, and even more years required to become clinical faculty, a generational gap exists between faculty and residents. Many of the faculty who educate medical students and residents today completed their training in the late 1970s or 1980s. And they teach according to the way they were taught by their faculty, who were trained in the 1950s and 1960s. It is easy to see from this model how fundamental educational priorities and principles could have failed to adapt since the early 1900s through just a few generations of educators. And as a result, expectations of trainees have also failed to adapt.

Although these educational expectations may not have adapted much during the past century, trainees’ expectations have changed dramatically. A host of information on generational expectations is available, and researchers have published a plethora of literature attempting to group certain generations and their social and philosophical attributes into quantifiable timetables. Possibly the most accepted descriptions of the generations can be found in Generations.⁶

The most notable generations of the past century are “traditionalists,” born 1925–1945; “baby boomers,” born 1946–1964; “generation X,” born 1961–1981; and “generation Y,” born 1977–2003. Each of these generations has a different outlook on life, freedom, religion, government, policy, social standards, and education. Some researchers have proposed that there is a trend over the past 4 generations toward a more family-based social structure.⁶ A greater emphasis on work–life balance is apparent with each generation. Freedom of choice and individual reward have emerged as products of the transformation of social standards and have a profound impact on education. This transformation has made it difficult for academic faculty to adapt to the new hierarchy of priorities among residents and furthers the conflict. Conflict lends itself to intimidation, and residents are pressured to conform to the training standards of the faculty’s generation.

Initially, this paradigm change seems discouraging, because as we know, generations will continue to adapt, and the conflict will continue to worsen. However, if the trend is recognized and mechanisms are put into place to change the expectations of supervising faculty, residency training can survive and flourish with the new ideals of younger physicians.

It is comforting to know that the medical education environment is not the only place where intimidation occurs. The generational gap conflict is present in almost all areas involving a senior supervising body and a junior workforce or trainee. We should be encouraged that this conflict has been addressed with great attention in the business world. Large companies have recognized this conflict for the past decade and have begun investing substantial amounts of dollars into training their senior staff and supervisors to investigate how to lead their teams in the face of changing expectations.^7,8

Through business literature and private studies, major companies have begun to reduce the generational gap conflict and improve productivity. This process has involved an overhaul of how many companies advance employees. Many buzzwords have evolved, such as “diversity training,” “corporate restructuring,” “generational education,” “sensitivity training,” “workplace violence training,” and “work–life balance.” If the medical field follows the progress made by the business industry, we too can have a positive impact on future training. After all, our goal is not to make more twentieth-century– minded physicians, but instead to train physicians to adapt to the needs of our patients, our students, and our communities. We must first recognize the conflict and develop goal-directed strategies to change the training environment for the improvement of graduate medical education.

Douglas Che Miller, MD
Secretary, Governing Council
American Medical Association
Resident and Fellow Section

References
1. AMA Member Connect^® Survey Program. AMA survey on issues of importance to resident physicians and fellows. Available at www.ama-assn.org/ama1/x-ama/upload/mm/468/mca06survehighlights.pdf.

2. Bliss M. William Osler: A Life in Medicine. New York, NY: Oxford University Press, 1999.

3. Cheadle WG, Franklin GA, Richardson JD, et al. Broad-based general surgery training is a model of continued utility for the future. Ann Surg. 2004;239:627-636.

4. Joyner BD. An historical review of graduate medical education and a protocol of Accreditation Council for Graduate Medical Education compliance. J Urol. 2004;172:34-39.

5. History and organization of the Accreditation Council for Graduate Medical Education. Accreditation Council for Graduate Medical Education. 2006. Available at www.acgme.org/acWebsite/25_anniv/25_history.asp.

6. Strauss W, Howe N. Generations: The History of America’s Future, 1584 to 2069. New York, NY: Harper Perennial; 1992.

7. Fiterman D. Bridging the generation gap in business [editorial]. Minneapolis/St. Paul Business Journal. August 15, 2003. Available at www.bizjournals.com/twincities/stories/2003/08/18/editorial2.html.

8. Warren C. Can’t we all just get along? American Way. August 15, 2006. Available at www.americanwaymag.com/PastIssues/August/152006/tabid/1895/Default.aspx.