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
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
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
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
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
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