HealthJune 22, 2020

How to identify a toxic residency program

By: Ogie M. Ezeoke, MD

All interns can attest to the challenges of residency training. But for some, these challenges may be exacerbated by being in a toxic residency program.

As the first year of residency comes to an end, you may be wondering if the difficulties you faced were due to the learning curve or because you struggled thanks to lack of support, punitive tactics, a culture of disrespect or the absence of positive reinforcement. The combination of these factors can place an immense burden on new residents who are encountering the responsibility of taking care of patients for the first time. These factors can also hasten the development of burnout in residents.

If you're in a toxic residency program, it can be difficult to distinguish true red flags from the normal challenges of being a resident. However, there are a few ways to make sure you're hearing the warning signals above the buzz of your pager. Picking up on these signs is the first step to taking control of your training and ensuring that you secure an environment that supports your growth as a physician and the growth of those who come behind you.

What “toxic” means in residency training

What makes a residency program “toxic"? Consider whether you're experiencing the following factors.

An abusive training environment

One challenge that comes with attempting to identifying a toxic residency program is that often, events that are toxic are sometimes ignored because they're thought of as a normal part of training as a young doctor. You may find yourself rationalizing abrasive behavior from colleagues or senior faculty, thinking that it's for the greater good of your training, or questioning your resilience after receiving disrespectful comments that were couched as constructive feedback.

While some directness is necessary in medicine, particularly in feedback, an interaction should never become abusive. If your training environment is a source of fear, that's extremely concerning. You may find yourself holding back from asking questions that are perfectly appropriate or choosing not to seek clarification about patient care because of how you've been treated before when you asked questions.

Unresponsive program leadership

An even bigger red flag can be a lack of appropriate response from program leadership when you bring these concerns to their attention. There's always the possibility of so-called “bad apples” in a program that disrupt a nurturing learning environment, but it's important that leadership takes appropriate action, including possibly retraining the offending individual.

It's problematic if your training program has a culture of blaming those who report instances of abuse, not protecting the privacy of residents who report incidents anonymously or allowing retaliation for reporting. It's also concerning when the onus of change for behavior in the hospital is always placed on the resident. Keep an eye out for language implying that older clinicians don't need to adjust their style or that it's a sign of weakness to want nonabrasive communication.

A lack of resident support

A more subtle sign of a toxic residency program can be lack of support for residents, particularly in times of crisis like the COVID-19 pandemic. Residency support usually takes the form of flexibility for residents who are parents, active adjustments for residents who may have underlying medical conditions or coverage for residents who experience family emergencies while in training.

Sometimes these supports exist but residents are discouraged from leaning on them when needed. Toxic programs may employ punitive tactics, including withdrawing certain benefits if residents use these resources or requiring that coverage that disrupts or unreasonably extends training be paid back.

How to spot a toxic program during residency interviews

It's important during residency interviews to look out for toxic residency programs, particularly if you're entering training for a longer residency such as a surgical specialty.

Some programs are skilled at displaying only the best aspects of the program during the few hours you spend with their team. This is to be expected, so to be able to identify toxicity, you must dig a little deeper.

Reach out to individual residents and ask questions about how they're treated by faculty and other hospital staff, what the culture of the program is and if they would go through training at the same program again. In COVID-19-era interviewing, where social distancing may mean entirely virtual interview experiences, this is even more critical in order to get the full measure of a program. As a medical student, consider any problematic events you may have witnessed or heard about during your clinical years. Ask a resident how the same scenario would be handled at their program.

Asking these questions will help uncover warning signs that may not be immediately apparent during a polished interview day.

Where to go when you're in a toxic residency program

As a resident, there's always the sense that you're tied to your program and that it's inevitable you finish your training with those with whom you started. This can foster a sense of camaraderie among your cohort and the feeling that you'll always have the support of your program as you progress through your training.

But the feeling of being tied to a toxic residency program may become suffocating. You may even feel overwhelmed at the thought of completing the entirety of your training. You should always remember that even if you bring problems to your program leadership and there isn't any change, you can file complaints with the Accreditation Council for Graduate Medical Education (ACGME).

In addition, you can get support from the other residents in your program. Sometimes, talking about incidents with your peers can help you figure out how widespread they are and encourage faster mediation from leadership. Faculty who aren't directly involved with leadership can also provide guidance to new residents about how to navigate a toxic environment. At the end of the day, you also have options for transferring residency programs.

Residency programs should be inherently resident-focused. As a new resident, your voice can help make this a consistent reality.

Ogie M. Ezeoke, MD
Lippincott® Medicine
Lippincott is a leading international medical publisher of professional health information for practitioners, faculty, residents, students, and healthcare institutions with a full suite of essential medical products, from books and journals to digital solutions.
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