LEARNERS AS TEACHERS - THE CONFLICTING ROLES OF MEDICAL RESIDENTS

OBJECTIVE: To explore the impact of internal medicine residents' roles as learners, teachers, and physicians on their performance in teachin g and supervising interns; to generate insights for educational policy and research. DESIGN: Qualitative analysis of in-depth, semistructure d, recorded interviews with a cohort of second-postgraduate-year (PGY- P) residents. Questions elicited their accounts of differences in the learning process between the first and second residency years, their r esponses to situations in which they lacked sufficient clinical knowle dge, their views of their supervisory relationship with interns, and t heir assessments of changes in their role in patient care since their internships, Transcripts were independently analyzed by the interdisci plinary team of authors. SETTING: New York University/Bellevue Hospita l Center's internal medicine residency (New York City), a highly compe titive program in a major public hospital and a university medical cen ter, emphasizing housestaff autonomy and self-reliance. PARTICIPANTS: A cohort of 18 of 21 medical residents at Bellevue Hospital Center dur ing the last rotation of PGY-P. RESULTS: Intense conflicts confound re sidents' roles as teachers. These conflicts fall into three categories : 1) as learners, residents' own needs frequently coincide with those of interns in ways that may undermine their teaching-they are expected to nurture others despite their own considerable needs for emotional support, teach material that they barely grasp, and exert authority wh ile feeling ignorant; 2) as team leaders, residents must ensure that i nterns get the hospital's work done, sometimes at the expense of teach ing them; and 3) as clinicians, residents' first priority is to addres s the medical needs of patients-the learning needs of interns are seco ndary. CONCLUSION: Second-year internal medicine residents experience conflicts inherent in their simultaneous commitment to learning, teach ing, and service that may undermine both their effectiveness in superv ising interns and their own professional development, Potential remedi es are to restructure residency programs so as to equip residents with training and support for their role as teachers, reduce the tension b etween training and service by delegating tasks to nonphysician person nel, and provide graded responsibility to house-staff as physicians an d teachers.