How Does Your Garden Grow?

July is an exciting time in the residency world. We welcome new residents, fresh out of medical school, full of excitement and energy and a desire to become excellent family physicians. A colleague of mine called them “pluripotent” new doctors with the potential to become many different things. Pluripotent is defined as being capable of differentiating into many cell types, (or, perhaps, doctor types). Some of these new residents will become hospitalists, some will become sports medicine doctors, and some rural, full-spectrum family doctors. All, however, will become caring family physicians, at least that is the goal. We have 3 years to mold them into capable family physicians.

What are the components necessary to nourish our residents? Residents enter our lives as new medical school graduates, full of basic science knowledge and hopefully an innate ability to talk to people. It is our job as family medicine faculty to turn them into accomplished physicians and healers. Much has been written about how to accomplish that task, including several articles in this issue of Family Medicine. ^1-4 These papers address methods for teaching about opioid use disorder, addiction medicine, point-of-care ultrasound, and geriatrics. Each of these topics are core components of a family medicine residency education. Being generalists, our residents need education about a multitude of medical, psychological, and social disorders. These topics are part of a standard 3-year curriculum that includes didactics, hospital rotations, and continuity clinic.

I like the metaphor of growing a flower. We start with a seed, plant it in the earth, make sure the dirt has enough nutrients to support its growth, ensure adequate water and sunlight, and finally, celebrate its beauty. Similarly, during the 3 years of residency, we take a newly graduated student, provide content education (sunlight), clinical experiences in the hospital and clinic (water), and watch them grow. But, there is more complexity and nuance than just watching them grow and singing “Oh how beautiful,” as Kipling wrote. We need to teach them to deal with uncertainty, to use multiple data sources along with experience to make medical decisions that are evidence based and patient centered. They need to develop resilience after adversity and to communicate with patients who are different from them and who are often facing many difficult challenges. These skills are often referred to as the “informal or hidden curriculum” and are harder to quantify. ⁵ A recent systematic review found key components of the informal curriculum that included teaching about cultural competence, medical professionalism and dealing with uncertainty.⁵ There is not much data on how best to teach residents this informal curriculum, and it is rarely explicitly outlined. It is easy to outline required knowledge about obstetrics, for example, and quantify procedures. However it is less straightforward to quantify learning these adjunct skills of communication, empathy, and dealing with uncertainty.

The concept of uncertainty is pervasive in a family medicine practice. As generalists, we are experts at differentiating between serious illness and conditions that do not threaten life. As such, we depend on our instincts (fostered by data, experience, and intuition) to make decisions. But, many nights we are all kept up worrying about whether we made the right choice. This uncertainty often leads to extra laboratory or radiographic testing, or closer follow up than necessary. Qualitative data suggest that residents’ ability to deal with uncertainty evolves with more experience as they progress in their residency, which makes sense. ^{6, 7} We can all see our first-year residents eyes get wide when we tell them that, yes, we may not know what is going on exactly, but we know it is not life threatening. Or when they negotiate with us about ordering tests that we may not think are needed. We can see them develop a more nuanced method of decision making that incorporates evolving confidence grown from hours and hours in the hospital and clinic. These changes are often subtle and happen organically over the 3 years of residency.

As we turn to cultivating our newly planted gardens, we should not only focus on the sun and water, but we should also attend to the pruning of our flowers, the mineral content of the soil, and protection from storms. Helping our pluripotent first-year residents become fully-fledged family physicians is a complicated and daunting process. At Family Medicine, we look forward to future research on these vital topics.