You may have heard the phrase “Don’t go to the hospital in July — that’s when all the interns start.” And while you might prefer to avoid seeing a brand-new doctor as you’re lying on an operating table, we all love to watch what residency looks like from the comfort of our couches. Shows like “Grey’s Anatomy” thrive on high stakes and complex relationships, while sitcoms like “Scrubs” entertain us with comedic daydreams and witty banter.
But what is it really like to withstand a grueling three to seven years of residency after four years of intensive study in medical school? Lucky for us, we didn’t have to go far to find out.
The Waco Family Medicine Residency Program is the oldest accredited family medicine residency west of the Mississippi River. Since 1970, family doctors have been trained here to help care for the poor and underserved in the community. Each year 12 new faces are added to the wall of residents at the Family Health Center as they enter what very well might be the hardest three years of their lives.
THE ROAD TO RESIDENCY
During the last year of medical school, students are looking ahead to the next step in their training: residency. Once they graduate from medical school, they are doctors in name but must complete residency, pass the board exam and obtain a medical license in order to practice medicine as a board-certified physician.
Dr. D. Mike Hardin Jr. is the program director for Waco’s residency program.
“Medical training is like an apprenticeship more than it is sitting in a classroom,” Hardin said. “It’s doing and seeing and teaching alongside each other rather than sitting in a class learning things.”
The residency program was created by medical, business and political leaders 48 years ago to provide health care access for underserved populations in Waco. Over time the Family Health Center was birthed out of the residency program, with 13 satellite locations now operating to serve more patients. Residents spend time practicing at the main Family Health Center clinic on Providence Drive, near World Cup Café, with rotations at both Providence Health Center and Baylor Scott & White Medical Center Hillcrest.
To get a feel for the culture of a residency program, students in their final year of medical school often choose to do rotations at residency programs they are interested in attending. First-year resident Dr. Steven Liebing attended A.T. Still University in Missouri and chose to come to Waco for one of his rotations. He was limited to two weeks instead of the usual four because his wife was due with their third child.
“When I came back several months later to interview, they remembered who I was, they remembered that we were gonna have a baby due in October and remembered that it was a boy and asked how [my wife and the baby] were doing,” Liebing recalled. “It was genuine that they actually cared about what I cared about, and that was impressive to me. It was not the case with other programs that I spent time with that were much closer to family.” In addition to the kindness from
the residency sta , Liebing also experienced the generosity of the community while on rotation.
“One of the local physicians, not affiliated with our program, was willing to house me, a complete stranger,” he said. “I was not used to that kind of hospitality.”
The Waco residency program gets an average of 900 applicants each year for 12 available spots. Only 110 are invited to interview. Then Hardin and his colleagues must rank each person from 1 to 110. All residency applicants in the U.S. rank their preferred programs in order. All that information goes to a nonprofit, nongovernmental organization called the National Resident Matching Program. Once all the applicants and programs have submitted their ranked lists, it all comes down to one thing — Match Day.
“We don’t have full control of the situation. The Match computer and God are in control of what’s happening,” Hardin said.
On the third Friday of March the NRMP releases the results of The Match, which sorts the applicants into residency programs using a computer algorithm to pair the applicant with the highest possible program from their list. Once matched, the student is committed to that program. And in the blink of an eye, the next several years are set.
Second-year resident Dr. Rachel Rube made her decision for residency based on advice from a colleague. “He told me that I should go to a program that had the type of people and the type of providers that I hoped to one day emulate, not just in a practice setting but in a holistic setting, in the way that I hope to be as a person in my community. I really took that to heart,” Rube said.
For her, Waco fit the bill.
“The caliber of people that I work with as colleagues and as my faculty, the attendings at the hospital, everybody really has a heart for the people that they are serving. That is momentous because if you don’t have that, this tedium that is jumping through hoops, that is trying to coordinate care, that is getting stuck with [socioeconomic] situations would burn you out to the point where you don’t have anything pushing you forward anymore,” she said.
Similarly, Liebing chose Waco, in part, based on his experience working with residents during his time here in medical school.
“In comparison to other places I had been, the residents were, from my perspective, outstanding and some of the best that I encountered,” he said. “I felt like I wanted to come here because if I could be half as good as them, then I would be the kind of physician that I wanted to be.”
Welcome to Waco
Before the July 1 start date, first-year residents, also called interns, attend a two-week orientation. A large portion of that time is spent team-building.
“One of the antidotes to burnout in training is having a great team of people that you work with and you relate well with,” Hardin said. “We do a lot of intentional things to develop those relationships.”
This team-building also involves the residents’ spouses, who are building their own support system among themselves because, as Hardin said, “It’s hard to understand what that life is like unless you’re in it.”
The interns are also oriented to the population they will be serving.
“We specifically take time where they have to understand poverty in Waco and the situations that our patients live in and how difficult it can be for them to get to the clinic,” Hardin said. “So they can understand when a patient shows up a half-hour late for an appointment it’s not because they were lazy or something else. It’s because they walked to get there, the bus was late, they couldn’t get a ride or whatever it was.”
Rube attended Baylor University as an undergraduate before going to University of North Texas Health Science Center for medical school. She said she’s learned about a completely different Waco since returning for residency.
“As a graduate coming back to Waco, I actually think I appreciate a whole lot more about this community than I did before,” she said. “I like Waco more now, seeing it for its diversity and its plethora of opportunity.”
The residency program offers a full spectrum of training, from pediatrics to adult care to geriatrics, including rotations in obstetrics, cardiology, orthopedics, critical care, emergency medicine, surgery and more. The training prepares residents to work in rural or underserved areas and care for a variety of needs.
“They have to have a little bit of education [across the medical spectrum] to know what they’re doing,” Hardin explained. “Doesn’t mean they’re going to be experts in those things. Their job is to learn what they can take care of and then what they need to send someone else to take care of. That’s the key decision a family doctor has to make.”
The experience residents get at the Family Health Center is unique because patients often can’t afford to see a specialist or get a recommended surgery, so the family practice doctors must address more issues by themselves.
Dr. Samuel Lindquist is a third-year resident who attended medical school at the University of Alabama. He is going to practice rural medicine in western Kansas after graduation.
“This program emphasizes reaching the underserved, reaching the patient population that falls below the poverty line and providing health care access. Being able to be part of that through this residency program is by far the most rewarding part,” Lindquist said.
Lindquist is one of 14 current residents who came to Waco from somewhere other than Texas.
“Sixty-eight percent of our applicants come from out of state,” Hardin said. “That’s a much higher percentage than other programs, and that’s because people want to come here to get the type of training we offer. Some of them go out to work in a rural area in another state, but they feel like they can’t get that training where they are.”
“The first year of residency is just diving in with both feet and just experiencing as much as you possibly can as quickly as you can,” Liebing said.
Every resident I spoke with laughed when I asked what a typical day might look like. There simply is no such thing.
Every four weeks they move to a different rotation. So one month they might be on an inpatient rotation, working at one of the local hospitals, and the next month they could be doing outpatient work at the Family Health Center. The following month they might be back at the hospital but on night shift. It constantly changes.
When I spoke with Liebing, he was on an outpatient month, which is a rare taste of normalcy.
“It’s 8 [a.m.] to 5 [p.m.], Monday through Friday, no weekends. It’s great,” he said. “It’s a nice relaxing time where you get to see patients more in the setting that I plan to do later on.”
In an outpatient month Liebing gets to wake up and have breakfast with his wife and three kids—ages 5,3 and 1—before going to work at the clinic. Then there’s time after work to play with the kids and put them to bed. After that he’ll read up on medical journals or perhaps do some woodworking, a leisure activity he says is therapeutic.
The outpatient rotation has a more normal flow, but it’s a rare season in the life of an intern. Most of the first year is spent on inpatient rotations, which means working 12 days in a row, getting a weekend off and then working another 12 days. Each week is 80 hours of work, not counting any personal time spent reading articles or preparing for presentations. Going through residency and maintaining a family life is no easy task.
“I basically come home to my other job,” Liebing said. “And a lot of times it feels that way because my wife needs a break, needs help. It’s my responsibility to take care of the kids just as much as it is hers. That makes it hard and it does wear you out, but the reward is that I have such a wonderful support system and a place that I belong.”
Instead of seeing medical school and residency as a time where life is put on hold, Liebing said he’s living it now. And it’s something the whole family is part of.
“My wife could make this infinitely more difficult, but she doesn’t because she never acted like this medical journey was my journey that she was hostage to. It’s always been our journey,” he said.
Liebing was warned, along with the other interns, that this would likely be the hardest year of his life, and while he says that it has been extremely difficult, he’s also been happily surprised.
“I’ve loved residency far more than medical school. I think a large portion of that has been due to the place where I’m at and the people that I work with,” he said. “It’s more rewarding because you’re actually taking part in the care of someone. You’re taking responsibility of a patient and are actually the one writing the orders, making the decisions and being the one who’s accountable for their care. That’s the best part. It’s because you’re getting to actually see the results from your effort. I think that it’s been much better than what I anticipated it would be.”
In the same month Liebing works his outpatient rotation, another first- year, Dr. Jennifer Jehnsen, is working an inpatient labor and delivery rotation on night shift.
Jehnsen starts work at Hillcrest at 6:30 p.m. Throughout the night she will deliver babies, triage patients and handle emergency room calls that pertain to pregnant women.
Jehnsen described the fear and wonder she experienced delivering her first baby.
“I was just thinking in my head, ‘Don’t drop the baby! Don’t drop the baby!’ When I finally caught the baby, it was just the most wonderful feeling,” she said. “That’s why I fell in love with obstetrics, and that’s why I want to continue delivering babies [as a family medicine doctor].”
In the morning Jehnsen does rounds, checking up on her patients and making notes for their care. At 8 a.m. the residents working at Hillcrest on both night and day shifts meet together for morning report. One of the faculty members will guide them through a teaching case by asking questions to clarify the diagnosis of a patient from the previous night and then to determine a treatment plan. After that, they split into teams and present every patient for the day, going over the plans for each one.
Once the patients are passed off to the day shift, Jehnsen comes home to sleep till 3 or 4 p.m. She’ll eat dinner with her husband, read some medical articles or study Spanish and start it all again.
Jehnsen, who graduated medical school from the University of Michigan, is completing the program’s Spanish track, which started this year. Once a week residents meet to role-play a medical encounter in Spanish. Then when Spanish-speaking patients come to the clinic, the resident will attempt to conduct the entire visit in Spanish. If they need any assistance, a certified Spanish interpreter is in the room to help fill the gaps.
“I think that’s the most important part of the track because the reason why I’m scared to use Spanish is because I don’t want that to ever compromise care if I don’t know how to say something,” Jehnsen said. “And if I have a backup with me, it’s a lot easier to at least try to speak it and not have the fear of not knowing a word or not being able to tell them something.”
One of the main aspects of family medicine is continuity of care — developing relationships with patients as doctors provide care over time. The residency program models continuity in the way the outpatient clinic is set up. All the residents are divided into four teams, and the clinic itself is divided into essentially four clinics. The patients stay with the same team, so residents provide care to the same people over the three years they are here.
Jehnsen has experienced this aspect of family medicine even in her first six months as a resident.
“I didn’t expect to have so much continuity with patients and recognizing patients when they come in for a second time and things like that,” she said. “For example, I had delivered this lady’s baby, and a few months later she came into the [emergency room] with gallstone pancreatitis. I recognized her, and I took care of her in the ER. And that kind of thing has happened to me multiple times.”
Throughout the first year, interns are paired with an upper-level resident, usually a third-year, for each inpatient rotation. The third-year teaches the intern and provides oversight. Interns are also assigned a faculty mentor for the duration of residency.
“The first year you don’t feel like a peon,” Rube said. “You don’t feel like you’re beneath anybody, but you also do feel that you have somebody to turn to that you always somehow feel like you’re striving to be like and you’re not there yet. And then second year you start to feel like you’re starting to get there.”
If the theme for year one is experience — see and do as much as you can — then the theme for year two is independence.
“We’re alone a lot and feel the heat of just having to make decisions on critical situations independently with confidence,” Rube said.
In the team model, while third-years are mentoring and teaching interns, it’s the second-years who are picking up any slack and making sure everything is moving forward. A typical inpatient team includes two first-years matched with two third- years and one second-year resident.
When I spoke with Rube, she was working an inpatient pediatric rotation on day shift. She spoke to me while she had a break in her day, during which she worked on charting. For Rube, her day starts at the hospital between 5:30 and 6 a.m. when she does rounds.
“Once I’ve visited all my patients, I’ve reviewed their charts, I’ve put in my notes and recommendations for the day, I’ve ordered what tests I need, I’ve reviewed what tests I’ve gotten, then you meet up with the group or the team that you’re on,” she said.
That 8 a.m. meeting is the same one that Jehnsen attends at the end of a night shift. Together, the residents go through the list of all the patients and discuss the care for each one.
“That model teaches you to think independently and then kind of confirm your thoughts and your diagnosis with the team later on,” Lindquist said. “We’re very team- oriented. There’s a constant rapport going on.”
That group time lasts until 9 or 10 a.m., and then everyone carries out the tasks for the day.
“As a second-year we usually go back to clinic and do a lot more clinic days, while the [hospital] service is managed by the first-years and third- years,” Rube said. “We have a lot more outpatient time.”
The second year is a time to develop a style of practice, Rube explained. It’s not a matter of knowing what to do for a particular case but rather how you’re going to go about completing all your responsibilities.
“Ultimately, you’re learning the art of medicine, where you realize there are so many things at play, that it’s not just about making the right choice of antibiotic or ordering the correct test that will tell you the answer you’re looking for. It’s about figuring out all the moving parts and how you can keep that well-oiled machine moving forward,” she said. “And also not burning yourself out and spinning your tires.”
Rube spends time at the clinic until noon. On that particular day she then attended a Grand Rounds conference, which is an academic presentation by one of the residents, before returning to the clinic. Afternoons could be spent seeing patients at the clinic or helping out at the hospital.
“Lots of back and forth,” Rube said.
In this season of independence, there’s minimal interaction with other second-years. But every Tuesday afternoon the first-years and second- years meet for Teaching Protective Time, one of the didactic portions of residency.
“That is kind of a sacred time for us, so to speak,” Rube said. “That is the time where you decompress and you actually see everybody for brief snippets between lectures or between activities and you catch up.”
The second year is also when the residents start to gain confidence in their abilities as a doctor. Usually, it starts when the new interns arrive and they get a glimpse of how far they’ve come.
“They always say you’ll feel like you didn’t learn anything till you meet the new interns. And our interns are fabulous and they’re all very well-equipped with the knowledge and they all have really good outlooks on how they’re going to tackle the next task, but they are still green,” Rube said. “When you are looked at for an answer to a question and it comes out easily, then you start to really find your groove.”
The distinguishing factor in the third year of residency is supervising. The goal is not to learn and gain experience for your own benefit but to pass on what you have already learned to the next wave of interns.
“You’re definitely orienting first-years to the hospital, the logistics of medicine, where they have a lot of knowledge from medical school, but it’s application of knowledge,” Lindquist said.
Lindquist was elected by faculty and fellow residents to be one of two chief residents during his third year.
“We work on the logistics,” he said. “We’re really a sounding board for faculty, but also we represent the residents to the faculty. In addition, we handle scheduling, any type of conflict.”
Lindquist was on an outpatient rotation. He described his workload for a week.
“As a third year, I’m here [at the clinic] at least four half-days a week. The rest of the time I’m at the hospital,” he said. “I work every other weekend and generally have one 24- hour shift a week. Generally three or four [12-hour shifts].”
Of course, the time devoted to residency isn’t limited to the hours spent at the hospital or clinic.
“Whenever I’m out of clinic, you have to stay up on telephone encounters, calls, prescription refills. [Preparing] if you have a presentation. Reading, just from a general medical knowledge. Staying up-to-date on journal reading,” he said. “Eighty hours a week underestimates what goes into it.”
As upper-level residents, second-years get to choose two elective rotations, and third-years get to choose three.
“They use those to tailor their training for what they’re looking on doing when they get out of here,” Hardin said.
For those who want to do rural medicine in another country, the residency program has a special track for global health. Residents in that track can choose, for instance, to take one elective in each of their second and third years to work overseas.
“Family medicine training is what’s needed to walk into a village in Africa and take care of whatever comes in your door,” Hardin said. “So the training they get in family medicine here enables them to be able to do global health work.”
Third-years are also preparing for the final board exam, taken in April. Their graduation does not depend on the results, but they must pass before becoming a board-certified physician.
To graduate, the residents must be capable of practicing medicine on their own.
“The goal at the end of the third year is to be ready for independent practice with no supervision whatsoever,” Hardin said. “That doesn’t mean you’ll know everything you ever need to know. Doctors learn something new every single day when they practice medicine. But they need to be ready to generally know how to take care of what walks in their door and then how to find the answer they need to know and apply it to that patient they are seeing.”
ON THE CUTTING EDGE
While the residency program has a set structure and curriculum, it’s also a place to dream new ideas and test them.
“The residency ends up being an innovator for the health system itself,” Hardin said. “We have the bandwidth and the spare time to come up with some of these ideas and work on them. And that gets pushed out to the system.”
One of those innovations currently being implemented in the Family Health Center is integrated behavioral health.
“[In] family medicine and medicine in general, you can’t fix everything. A lot of problems are related to lifestyle, psychological issues, spiritual issues, all kinds of things,” Hardin said.
To help address some of these other issues, each team at the clinic has a psychological provider on staff. So if a patient comes in for a physical ailment and the doctor learns about some other lifestyle issue or mental illness, such as depression, then there’s a professional in the clinic who can come and discuss those areas the doctor doesn’t have time to dig into. Then the two providers work together to tackle the issues needed to improve patient health.
“We’re probably the only residency program in the state that has this degree of integration in behavioral health in our clinic,” Hardin said. “This is on the leading edge of what’s happening in medicine, so this is really cool and we’re really excited about it.”
The residency program also launched a program called Centering Pregnancy, which provides prenatal care in a group setting. Eight to 10 pregnant women who are due in the same month attend their appointments together in 10 sessions that cover topics like healthy eating and exercise while pregnant, labor and delivery techniques, and caring for a newborn. Exams are done in private rooms.
“Two things that have been associated with this is improved adoption of breastfeeding and decreased preterm birth,” Hardin said. “And decreasing preterm birth is a huge thing in terms of health of kids and medical expense as well.”
A DEMANDING LIFE
Residency requires a great sacrifice of time, not just in the three years it takes to complete the program but also in long hours, day in and day out, devoted to working and learning. Yet the residents I spoke to did not seem overly burdened by the amount of work.
“Free time is much briefer than it once was, but I think it’s appreciated much more,” Rube said. “You can find an hour or two each day, even if it’s not all at once. Sometimes it’s just 15- minute snippets that you piece together in a couple of hours where you could do something more leisurely.”
For Rube, that’s doing a crossword puzzle with her husband. Lindquist uses his free time to go running at Cameron Park. Liebing spends time in his woodworking shop. And Jehnsen likes to try new restaurants with her husband on her weekends off.
“The time just passes so fast because you’re learning so much and you’re enjoying your work, and your patients are so appreciative and great,” Jehnsen said. Mentally, working a lot has been fun and I’m enjoying it, so that has surprised me a lot. I’m not as tired as I thought I would be just looking at the raw numbers of work.”
Lindquist has found that he has more free time in his final year of residency.
“I’m as busy or busier, but I’ve learned to manage and be better at efficiency,” he said.
When, then, is the hardest part of residency?
“It’s more the human side of medicine,” Rube said. “Realizing that I am responsible for these lives, these people’s health, and that it is my due diligence to make sure that I put forth the best effort, allocate the best resources, get them plugged in with the most appropriate specialists and/or opportunities that [they can afford] outside the doors of my clinic and the hospital. Struggling with that is hard.”
The residents all pointed to the mental stress of providing care and facing obstacles with patients who lacked funding for treatment as the most difficult part of residency. But stepping back to look at the big picture helps give perspective.
“You have to kind of center yourself in what’s the most important,” Rube said. “And the values of this institution and each person that’s in it honestly reminds me every day why I wanted to do this.”
Finding support from faculty and fellow residents can ease the burdens of residency. There’s also the simple benefit of seeing the fruit of your labor.
“I love what I do,” Lindquist said. “There is something gratifying and rewarding about seeing people get better.”