The conversations behind the letter
Siegel, director of the Yale Traditional Internal Medicine Residency Program and a professor of pulmonary medicine, reported being nearly three-quarters finished with his annual meetings with second-year residents, or PGY2s. He schedules the hour-long conversations early in the academic year, beginning with second-year trainees before meeting with first- and then third-year residents.
Most second-year residents enjoy the chance to think, teach, and take a broader view of patient care, he wrote. But discussions about research, leadership, well-being, and career plans also reveal concerns that recur each year.
In a June 2026 interview with Yale Insights' Health & Veritas podcast, Siegel said he oversaw 157 trainees and met with every resident for about an hour at least annually, as required by the ACGME. He also said he had been sending his Sunday Program Director's Note letters weekly for close to 10 years.
The advice comes from a program whose residents have helped shape its structure. Siegel credits them with helping eliminate 28-hour call and develop the 6+2 block scheduling system, MAC program, and Distinction Pathways. In the podcast interview, he said eliminating overnight call was intended to allow residents to sleep. He described the program's motto, "As good as any, nicer than most," as a value it puts into practice.
Taking a demanding night one task at a time
Siegel described the move into a senior role as harder than the transition into internship. By the end of their first year, residents can handle admissions, orders, documentation, and handoffs and recognize which patients need intensive care and which can go home. Yet those skills cannot fully prepare them to lead resuscitations, answer colleagues' questions, and supervise interns as the floor's most experienced resident.
For nights crowded with messages, new admissions, and deteriorating patients, he borrowed an example from Anne Lamott's Bird by Bird. Lamott recounts how her brother left a school report on birds until the night before its deadline and became overwhelmed. Their father's advice was: "Bird by bird, buddy. Just take it bird by bird."
Siegel recalled wondering during residency how he would get through the night. His advice to new seniors was to approach the workload in manageable pieces, attending to one patient or task at a time until morning.
Lamott's book, subtitled Some Instructions on Writing and Life, was first published in spring 1994 and has sold more than a million copies, according to The New Republic. Siegel's own education began with an English degree at Columbia University. He later earned his medical degree from Columbia College of Physicians and Surgeons, completed internship and residency at the Hospital of the University of Pennsylvania, and joined Yale's full-time faculty after finishing a pulmonary critical care fellowship there in 1995.
Giving interns room to learn
The efficiency residents develop during internship can make it tempting to keep doing the same work themselves. Siegel urged new seniors to resist taking over routine patient examinations, lab checks, consultation calls, and notes. Dividing too much of that work with interns can limit their learning while leaving seniors less time to teach, read the medical literature, and assess the overall clinical situation.
The aim is not to overwhelm interns, he wrote, but to help them become independent. That includes giving them a chance to propose decisions rather than routinely telling them what to do. A senior might ask how to respond to a fever, what could explain a rising anion gap, or why a patient's oxygen saturation is dropping. Emergencies sometimes require direct instructions, but questions should generally give interns room to reason aloud.
Prepared whiteboard talks and slide presentations have a place during quiet afternoons or overnight downtime, Siegel said. Still, he considers everyday rounds the most important setting for teaching. Asking interns to interpret arterial blood gases and EKGs, or explain free water deficits and antibiotic choices, lets seniors identify what they understand and supply explanations where needed.
Confidence is not the same as certainty
Siegel cautioned against treating certainty as the measure of a good physician. A diagnosis reflects the disease judged most likely, while antibiotics may be necessary for possible sepsis because treatment cannot wait for complete certainty. He argued that humility and willingness to accept correction matter more than appearing sure of every decision.
The colleagues residents admire may look composed while recognizing the uncertainty behind their choices, he wrote. He also addressed unfavorable comparisons with peers who seem more capable, confident, or accomplished: those same peers may be making equally flattering comparisons in the other direction.
Leaving room for career choices
Residents need not have their careers settled just because some colleagues already do, Siegel wrote. Many remain undecided or change direction. Exploring subspecialties takes time, and enthusiasm for a broad range of medicine may also be a reason to consider general medicine.
Although most residents submit fellowship applications at the end of their second year, that timetable is not mandatory. Siegel spent a year after residency working as an emergency room attending at Pennsylvania Hospital. He noted that a year or two as a chief resident, hospitalist, or primary care physician can also provide additional clinical, research, and leadership experience before fellowship.
He applied the same emphasis on individual interests to scholarship. Scientific research is one route into academic medicine, and the program has projects and mentors for residents who want it. Quality improvement and medical education offer other opportunities. His advice was to pursue work that genuinely interests them, rather than undertake research simply to satisfy a perceived requirement or demonstrate their worth.
