I enjoy teaching residents and believe that helping those who are struggling is possibly the greatest impact we can have. Whereas in our clinical work we help one patient at a time, teaching residents allow us to help exponentially more patients by extending our expertise geographically outward and temporally forward. I have noticed, however, that the effort required to train residents is not incentivized. Here are 3 reasons why many attendings at academic institutions have little interest in expending anything beyond the minimum effort required to train residents:

1. It is very unusual these days for a graduating AP/CP resident to find a job in the absence of one or two subsequent year-long subspecialty fellowships. Awareness of this fact means that attendings do not feel as strong a sense of urgency to ensure that their residents hone their clinical skills sufficiently before they graduate, since they will have more time after they graduate before they apply for a job. At that point it will be someone else’s responsibility.
2. Residents are given the opportunity to evaluate their attendings in an anonymous fashion. Negative evaluations affect our ability to be promoted academically. This matters because academic level affects our reputation and salary. Many attendings have found that the easiest way to get good evaluations is to keep their mouths shut when residents are under-performing and to take the work themselves. Trying to help a resident who is under-performing can be emotionally taxing and even risky. First, you will inevitably hurt their feelings, no matter how gently you broach the subject and however well you “sandwich” the negative aspects between protective layers of positive feedback. Many of us don’t like hurting people’s feelings in the short-term, even if it will help them succeed in the long term. Second, while some residents appreciate the effort and risk that attendings take in helping them remediate their skills – others retaliate – and what better forum for retaliation than an anonymous online system.
3. Academic promotion (at least in my institution and probably many others) also depends on teaching medical students. We are expected to log every teaching activity with the medical students, and each type of teaching activity is assigned a certain number of points.  On the other hand, while we are tacitly expected to teach residents while on service, there are no repercussions for abrogating this responsibility. If we tell the residents that they are doing a good job and give them good evaluations (i.e. quickly click on high scores in an online form), then often no one will complain. Medical student education is therefore prized more than residency education, despite the fact that teaching pathology to medical students probably has little importance beyond helping them pass Step 1 of their boards.

Of course, it is easier to identify problems than it is to propose solutions. In the future, I hope to write about ways we can incentivize quality pathology residency teaching.

I’d love to hear your thoughts.