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It is hard to be a program director; it seems especially hard now. A program director's time is consumed by scheduling, resolving conflicts, dealing with residents who are not performing well, trying to recruit reluctant faculty, and responding to a variety of regulations, including the institutional and program requirements of the Accreditation Council for Graduate Medical Education. Further, the work of program directors is not always recognized for purposes of academic promotion. It is viewed primarily as an administrative function, but nothing could be farther from the truth.

Dee Hock said, “Substance is enduring; form is ephemeral. Preserve substance; modify form; know the difference” (1, p 198). Much of our time is consumed in responding to the changing forms of medicine, yet much of our satisfaction is derived from preserving the substance of medicine. Teaching is part of that substance and has been since the time of Hippocrates. Identifying good people, promoting their professional formation, and assessing their competence is hard, yet the very thing that makes it hard can also make it deeply satisfying. It is impossible to engage in the formation of physicians without going back to our own formation, understanding it deeply, and recalling our own individual creative response to the vocation of medicine. The substrate of a program director's work penetrates to the heart of medicine, to its deepest values and traditions.

One of the many skills needed by program directors is the ability to distinguish illusion from reality. The idea of a program is itself a bit of an illusion. It is a mental construct that allows us to organize our thoughts and activities around education. Yet, the only real things in a residency program are the people in it and their relationships with each other. Some of these relationships facilitate learning, and some inhibit learning, which is interesting to consider. Which types of relationships foster good education? Which inhibit it? My own bias, as a former program director, is that the most helpful relationships provoke reflection, are accompanied by generative conversation, and provide role models. Education is not a productive art; it is a cooperative art. The quality of the relationship affects the quality of the educational outcome.

In a sense, program directors are in the discernment business—discerning the difference between good teaching and bad, and discerning growth in the capacities of their residents. It helps to understand competence. Competence is not the ability to pass a test; it is a habit. It goes beyond mastering knowledge and skill; its ultimate product is good judgment. It is acquired in private reading and reflection but even more so in social settings with colleagues and mentors. Parker Palmer, in his book To Know as We Are Known, quotes Abba Felix, a desert father who said, “To teach is to create a space in which obedience to truth is practiced” (2, p 69). The work of the program director is to facilitate space, time, and relationships in which discernment and obedience to the truth can be accomplished. It is noble and deeply satisfying work. It may be all that stands between good medicine and the barbarians.

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References 

References
1. Hock D. The birth of the chaordic age. San Francisco, Calif: Berrett-Koehler; 1999;
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2. Parker P. To know as we are known: education as a spiritual journey. San Francisco, Calif: Harper; 1993;
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