The Challenge: To Improve Residency





By:  The Generation Y Surgeon (@GenYSurgeon)


If you’re reading this right now, chances are you’re a surgeon, almost a surgeon (resident), or you’re a medical student who wants to be a surgeon.  We each have (or will have) a niche, but regardless of specialty there’s one thing we all share…the pain of residency.

When I matched, I had no idea what it really meant to be a surgical resident.  By that, I mean I didn’t understand what the true costs were.  I had thought long and hard about the long hours and extra years of training and the “hardcore” nature of surgery yet I failed to identify what really makes residency miserable.  What is it that turns optimistic young interns into gruff, imposing chief residents?  How does the young attending get to be as jaded and emotionless as the dinosaurs that lead our M&M’s?  Why are we so unhappy during residency and why do so many surgeons say they wouldn’t do it again?  I think about this a lot because I’d like to make residency a better experience, and because happier people make happier and more productive physicians.

Residents lose themselves somewhere in the middle of residency because they lack a sense of achievement, power, and a sense of affiliation.  We lose out motivation in the early years, succumb to the pathologic culture of surgery, and then we persist in that same miserable state because we don’t know any other way to teach or interact with each other.

Why?  I think this is explained by McClelland’s Needs Theory.   McClelland was a psychologist whose career centered around the science of workplace achievement.  In his theory, he proposed that a person’s needs are acquired over time and shaped by one’s life experiences.  Motivation and effectiveness in the workplace are influenced by three needs: achievement, affiliation and power.  I’ll go into more detail about each and how this pertains to residency below:

1.  Achievement: attainment of realistic but challenging goals, advancement in the job, feedback and progress, and a sense of accomplishment.  McClelland argued that achievement is more important than material or financial reward, and that financial reward is simply a measurement of success.

Surgeons are bad at giving feedback and even worse when it comes to giving positive feedback.  We rarely recognize, let alone validate, hard work and sacrifice among our peers.  We are quick to correct, quicker to scold and frequently guilty of downing others when our egos are threatened.  Residents, students and even attendings need little more than a pat on the butt for a job well done.  We don’t need coddling, but we do need to cut ourselves some slack and start giving each other some credit.

2.  Power: this is NOT power in the sense we want to be able to control others.  Power, here, is the ability to control our life and time.  It’s a focus on the ability for us to influence when and where we do things.

Power is often the first need to be stripped from a resident.  You lose control of your time, your autonomy and even your own bodily functions.  You are told where to be and when to be there, how to look, speak and walk.  Even your desires are dictated to you – research, fancy fellowships, high-paying jobs that you may not find fulfilling.  As a junior, your differentials/plans are frequently dismissed and for as hard as you work you are still treated as the smallest part of the team.

3.  Affiliation: motivation and need to be liked and held in popular regard, to interact positively with others who hold the same goals and gain approval.

In general, surgeons do not “play well with others”.  We often feel we work alone in our clinics and other venues.  When we do come together it’s over controversial and heated M&M’s or stressful exams.  We do have a few conferences and meetings that we seem to enjoy, yet as far as team building goes we are pretty bad at it.

In summary, we need build a training system that breeds confidence and power through achievement to keep our residents (and ourselves) motivated and productive.  We all motivate ourselves with some combination of the above described needs; it’s how we power(ed) through residency.  But what would it be like if we weren’t stripped of these needs?  What would it be like if we felt accomplished, powerful and autonomous yet part of a strong group of similar people?

I challenge you to use this knowledge in your workplace.  Start building a culture that breeds motivation and you will quickly find yourself among happier, more productive staff.  You may even find yourself a different person…

What are your thoughts on what really makes residency painful? Do you see a place for McClelland’s theory in your workplace?

Thanks for reading, I look forward to hearing your opinion.  Special thanks to SBMI for bringing me into the light.


True stuff.

The challenge is greater now than in previous generations, I believe, because the teachers see the learners as very different from themselves, exacerbating the usual 'kids these days' gripes. Every time I hear 'shift mentality' and '80-hr work week' I hear resignation, when what we need is inspiration.


@porteronsurg  @genysurgeon

I agree completely.  Everything has changed, not just the work hours. And 80hrs is still a lot of time!  I can sympathize with the dinosaurs however.  As the younger generations stuggle to fit new technologies and standards into yesterday's culture we forget that technology has left the older generations at a disadvantage.  Many (maybe most) have been passed up and we should do a better job of teaching them how to EFFECTIVELY USE technology so that they can more effectively teach.


Interesting post about McClelland's Needs Theory.  Definitely different than other motivation theories like Maslow's and some say McClelland's has evidence behind it where Maslow's is intuitively satisfying but doesn't.

Anyhow, this is an interesting explanation about what happens to us during residency.  I remember many of the same thoughts during my residency.  Wonder what everyone else thinks.