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Daugherty SR, Baldwin Jr DC, Rowley BD. Learning, satisfaction, and mistreatment during medical internship: a national survey of working conditions.  JAMA.1998;279:1194-1199.
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Resident Forum
December 16, 1998

Residents and Patients: Enjoying Your Patients

Author Affiliations

Prepared by Ashish Bajaj, Department of Resident Physician Services, American Medical Association.

JAMA. 1998;280(23):2036E. doi:10.1001/jama.280.23.2036

A recent article in JAMA, "Learning, Satisfaction, and Mistreatment During Medical Internship: A National Survey of Working Conditions,"1 discussed the working and learning environment during the first year of residency training. While many residents may focus on the mistreatment section of the study, I would like to focus on the learning and satisfaction results. The study found that the two factors contributing the most to satisfaction were relationships within the hospital and positive learning experiences. The importance of relationships was also seen in the factors that contributed the most to learning, the two most important of which were other residents and special patients.

When I think of my special patients, I remember the ones whose personal or medical situations seemed unique. As physicians, we learn something from each patient we see, but I admit that I remember patients who are famous or associated with famous situations. I've treated a well-known football player and someone who survived Auschwitz. I also remember a patient I treated several years ago because I learned that 30 years earlier, he had known my great-grandfather. Although I didn't consciously give him preferential treatment, he became a "celebrity" in my mind, and I remember well the details of his case.

It is easy to see the root of negative relationships with some patients; they are suffering and can be very difficult to work with. On top of that, our work hours and working conditions (including perceived mistreatment) create a highly stressful environment that can encourage the adoption and acceptance of negative attitudes toward patients. However, as the survey shows, patients can contribute a lot to our positive experiences during training, so we will benefit from improved patient relationships.

As mentioned in the survey, the other main piece of the puzzle is our fellow residents, who contribute most meaningfully to learning. Because residents train each other and set the tone in the wards, they are in the key positions to change other residents' attitudes.

The key to enjoying patients is having other residents and attending physicians emphasize the importance of positive patient relationships. No organizational or institutional policy can be as effective as peer feedback and emulation of a role model in changing resident behavior.

One way to foster change would be to move rounds back to the bedside—now, a somewhat lost practice—which would foster more personal relationships with patients. When one is at the patient's bedside, the patient ceases to be just a diseased heart or kidney and becomes a true person. We are more likely to learn something interesting about patients if we spend more time with them. I would never have learned that my patient had known my great-grandfather if I had not taken the time to talk with him. Finding a way to make each patient unique to you will improve learning and enhance patient care and satisfaction.

At the bedside, the patient becomes the center of the physician's attention. Presenting a patient's case in his or her presence changes the presentations dramatically, invariably for the better. It also offers junior residents and students more opportunities to view interactions between attending physicians and senior residents, providing them with visible models of professional behavior. Additionally, teaching physicians can provide direct instruction in observation and physical examination, skills that are increasingly endangered among new physicians. It is also important that the positive attitude toward patients continue into the doctor's lounge, the elevator, and all other areas of the hospital. If they do not, or if the attitude is seen as disingenuous, confidentiality and professionalism will be undermined.

As physicians, we face assaults from many sides. Social, economic, political, and medical developments threaten not only our livelihoods but also our standing as a respected and trusted profession. A key step in recapturing and maintaining our standards is to reassert the patient as our focus and, perhaps, even as our friend. Enjoyable relationships with patients are critical to our survival and our success.

Daugherty SR, Baldwin Jr DC, Rowley BD. Learning, satisfaction, and mistreatment during medical internship: a national survey of working conditions.  JAMA.1998;279:1194-1199.