Chief Residency
Article Outline
- Structure
- Characteristics of a Chief Resident
- Chief Resident Selection
- Duties of the Chief Resident
- Disadvantages of Chief Residency
- Rewards of Chief Residency
- References
- Copyright
Hand picked, with qualities of a young Sir William Osler, Sigmund Freud, and Henry Kissinger, his/her domain is the beveled slippery interface between the faculty and the housestaff.
Hardison and Garner (1)
It is said that the concept of chief residency originated with Dr William Halstead, chief surgeon at The Johns Hopkins Hospital, Baltimore, Md, in the late 1800s, as house staff training systems were developing in conjunction with medical specialties (2). If so, then one of his trainees must have been selected the first chief resident. Perhaps he (no women were allowed in those days) was given the responsibility of maintaining service coverage by residents, operating schedules, and resident attendance at surgery, on the wards, and in the clinics. From this humble beginning, a system developed whereby a senior resident was honored with the title of “chief” and spent a designated period of time, usually 1 year, in an illustrious role from which a notable career developed.
Such may be the case in the surgical specialties, where the chief resident controls the operating and work schedule and thereby determines the experience to be gained by others. The surgical chief resident occupies a top hierarchical position within a pyramidal system that mandates a chief resident year before completion of residency. The competitive victory of being selected chief resident guarantees the victor a position of respect and authority. Other large services, such as internal medicine and pediatrics, designate the chief residency as an additional year of training. In these instances seniority leads to teaching and service responsibilities similar to those of a fellow or a junior faculty member.
Radiology chief residencies may have begun similarly but have evolved into a different model. The radiology chief resident's role in the present-day teaching program is largely administrative. Work schedules, call schedules, teaching schedules, and annual rotation schedules occupy a major portion of the time. This is true for other hospital-based specialties as well (3). Teaching of junior residents at the view box or workstation is performed equally by all senior residents within subspecialty service rotations, and only formal teaching conferences need to be arranged by the chief resident. Therefore, teaching is not as closely associated with the radiology chief residency as it might be with other services. The chief resident, however, is called on to represent the residents to the faculty (4) and is expected to work closely with the residency program director\Mthe faculty's representative to the residents—in implementing the teaching and service objectives of the department.
Structure
A single chief resident is designated for most programs, particularly when the teaching program is concentrated at a single facility. Most large programs within a multi-institutional system have two or more chief residents so that there is a chief at each facility (4). Such would be the case when resident clusters are maintained at a university hospital, community hospital, children's hospital, and/or Veterans Affairs facility. Co–chief residents are also preferred when there is need for continuous availability that would not be compromised by isolated rotations (eg, Armed Forces Institute of Pathology, angiography, and interventional radiology). Shared responsibilities also reflect concern about interfering in the educational program of the chief resident, who needs time for study and intensive clinical and research experience. The sharing of chief residency responsibilities allows more time for other activities.
In the past, most chief residencies coincided with the July–June academic year (4). Before long, an earlier start and finish date evolved. Three months of lead time (April–June) allows the incoming chief resident to work with the outgoing chief resident and program director in preparing the following year's schedules and programs. Earlier appointment is also convenient in allowing the incoming chief to be introduced to the role by attending the annual meeting of the American Association of Academic Chief Residents in Radiology (A3CR2, pronounced “A cubed, CR squared”). This meeting is held each spring in conjunction with meetings of the Association of University Radiologists and other affiliated educational and research organizations (eg, the Association of Program Directors in Radiology [APDR]).
Another change has evolved in the appointment of chief residents. Fourth-year residents have become increasingly preoccupied with preparation for written and oral American Board of Radiology (ABR) examinations. In addition, they need time to finalize plans for the fellowship or practice year that follows. Given these demands, chief residents' duties become more of a distraction and disadvantage. Therefore, the timing of chief resident appointment has shifted from the 4th to the 3rd year of residency (5), with the term often extending from the spring of the 2nd year to the spring of the 3rd year. In the 4th year, the senior chief resident could be freed from administrative duties but still play an advisory role to help ensure continuity.
Characteristics of a Chief Resident
Not every good resident has the aptitude or desire to be a chief resident. A chief resident needs exceptional organizational abilities and interpersonal skills. Firm leadership and a knack for diplomacy are essential in dealing with the career development of a diverse group of individuals (6). Popularity and respect from both residents and faculty are also important. The extra time commitments make it essential that the appointee be academically accomplished. It is not necessary for the chief resident to be the brightest resident in the program, but he or she must not need to struggle to keep up academically. In addition, a resident oriented toward research might prefer to have more time for research without the added responsibilities of chief residency. In describing the necessary characteristics of a psychiatry chief resident, Lowy and Thornton mentioned “leadership potential, mediation skills, capacity for self-direction, tolerance for ambiguity, optimism, and the ability to use humor” (7).
Chief Resident Selection
In the past, the chief resident's appointment by the chairman was a reward for good work performed previously and an anticipation of continued support in the future. This concept may still pertain in many departments, but there appears to be a trend toward a more democratic process of selection (8). The program director, the education committee, and/or the executive committee also may have an important influence on the selection or nomination of the chief resident.
There is a strong argument for having the residents themselves make the nomination, with final approval reserved for the chair. If the chief resident is to serve effectively as the residents' representative to the departmental administration, then he or she should have their respect and confidence. The residents may be best informed as to who will serve their interests, as well as those of the department. This procedure also would help to minimize any perception of the chief resident as a pawn of the administration. However, the chair, in consultation with the program director, still needs to have final authority over the appointment of chief residents, as of all faculty members. It is most important that the chief resident, while representing the residents, also reflect an appropriate image of the department to the institution. The chief resident must have strong enough credentials to ensure his or her success both academic and administrative.
Duties of the Chief Resident
The chief resident's major responsibility is to ensure that the resident component of the clinical operation and the educational activities of the residency are optimized and effective on a daily basis. Most of these objectives can be accomplished by developing and monitoring the various clinical service assignments and teaching schedules within the department.
The first and perhaps most difficult schedule involves the residents' educational rotations for the coming year. The major objective is to meet the standards of the curriculum, but a balance must be maintained to optimize both the experience gained by upper-level residents and the basic background provided for junior residents. Although the faculty is responsible for teaching, there is much to be gained from the experience of more senior residents who share subspecialty assignments. The personalities of the faculty and their clinical strengths and weaknesses need to be balanced. While the incoming and outgoing chief residents may work together to develop the first draft of the annual rotation schedule, the final copy must be approved by the program director. Numerous revisions can be anticipated as the desires of the residents become melded with the educational needs of the curriculum and the clinical needs of the department. Rapidly expanding clinical demands, expansion of service sites and facilities, and changes in faculty or fellow coverage may dictate unanticipated changes in the curriculum. Consequently, the chief resident must be ready for unexpected modifications and assist the program director in meeting the educational objectives of the curriculum.
The scheduling of night and weekend coverage is also difficult. Off-hour activities have become more intensive, as many services are expected to provide active on-call, or even on-duty, coverage 24 hours a day, 7 days a week. Once again, balance must be maintained to ensure that those providing the services are appropriately matched with the other residents, fellows, and faculty on duty. Additional complexities may be caused by state regulations limiting the number of consecutive hours and days that a resident can spend on duty, as in New York.
A recent report by the Accreditation Council for Graduate Medical Education Work Group on Resident Duty Hours (9) recommends the following: (a) residents must not be scheduled for more than 80 duty hours per week, averaged over a 4-week period; (b) residents must have 1 day in 7 free of patient care responsibilities, averaged over a 4-week period; (c) residents must have call no more frequently than every 3rd night, averaged over a 4-week period; (d) there must be a 24-hour limit on on-call duty, with an added period of up to 6 hours for inpatient and outpatient continuity and transfer of care, educational debriefing and didactic activities; (e) a 10-hour minimum rest period should be provided between duty periods; and (f) when residents take call from home and are called into the hospital, the time spent in the hospital must be counted toward the weekly duty hours limit. The Association of American Medical Colleges has endorsed these recommendations. The chief resident also must ensure equality in total number of assignments or face the wrath of the “abused” residents and their families. The scheduling of off-hour coverage is a stringent test of the chief resident's leadership, authority, and compassion.
Almost as difficult as scheduling on-service needs is the scheduling of off-service obligations. These include vacation, travel to meetings, time spent at the Armed Forces Institute of Pathology, and holidays. Once again, the chief resident must be fair, equitable, and consistent in accommodating special needs and requests while ensuring adequate coverage of patient care services, an appropriate mix of residents on duty, and an appropriate sequence in resident rotations. Scheduling for special needs becomes even more complex with dual-career couples, particularly when both careers are in the same department.
Various intramural moonlighting schemes have evolved whereby extra compensation can be offered for in-house coverage or coverage within a system that involves other institutions. These services can be accommodated on duty, on call, or by means of teleradiology. There have even been moonlighting schemes for off-hour training in sonographic and radiologic technology. The chief resident is responsible for selecting residents who will benefit from these opportunities.
Personnel management is the next major responsibility of the chief resident. Besides the usual day-to-day issues encountered within a department, interdepartmental issues occasionally need to be addressed. When a resident from another service behaves inappropriately toward departmental personnel, technologists, house staff, or even patients, the chief resident can defuse a volatile situation by approaching the appropriate chief resident colleague. Residents are territorial and protective of their own groups but are also concerned about the image of their department within the institution. They generally welcome the opportunity to deal with issues at the resident level before involving program directors, section heads, or chairs.
Similar opportunities exist within the department for dealing with residents who have problems that are affecting performance and morale. In addition to acquiring the knowledge and technical skills needed to be good radiologists, trainees also must learn to be effective members of a health care team. When a resident has a problem, that resident's colleagues are usually the first to become aware of it and are best suited to address it before it becomes too advanced (10). The chief resident plays an important role in the early stages but must be prepared to involve others when the need arises. The program director usually has counseling resources available to help with problems such as uncontrolled rage or sexual harassment.
Problems with the attending radiologist are usually referred to the program director, but the chief resident is often an intermediary, bringing issues forward discreetly and effectively. Attending radiologists cannot be everything to everybody. Some are valued for their research or clinical expertise but lack the ability or compassion for teaching. Others may be superb instructors at the view box but have difficulty lecturing in a formal classroom setting. The optimal use of staff in a teaching environment often requires adjustments and compromise.
Chief residents are the key recruiters for their departments. Being more knowledgeable than are many faculty members about the various clinical and teaching programs in the department and affiliated institutions, they are asked to interview candidates for positions at all levels, from prospective residents to prospective chairs, and they often lead tours of the clinical facilities. Residency candidates are most interested in residents' opinions and attitudes about the department, and they recognize that the chief resident is a true representative of the house staff program. Chief residents are instrumental in preselecting applicants for interviewing and usually in determining the final rank-order list. They select other residents to meet with the candidates, and they arrange lunches and other recruiting events. Because chief residents take the lead in recruiting medical students, they are generally the first to hear from residents in other programs who are considering a transfer to radiology.
Faculty candidates are also interested in the chief resident's perspective on operations of the department or section they are being asked to join. A candidate for chair would be foolish not to insist on time with the chief resident, taking an opportunity to get a true sense of the department's good and bad sides.
The chief resident is involved in all aspects of resident selection: recruitment of candidates, preinterview selection, interview schedules, encouragement of favorable candidates, and the final ranking process. Activities do not stop there. Successful candidates continue to need advice and assistance as they prepare for residency. Chief residents help with preliminary study plans and even give advice on relocation.
As a participant in resident selection and education, the chief resident is included in various departmental administrative committees. Resident participation is important in the various clinical operations groups and even the departmental executive committee. The central house staff office also seeks chief residents' participation in institutional activities and is most interested in opinions from hospital-based services such as radiology.
A3CR2 has conducted an annual survey of chief residents since 1971. The survey results are stored in a database maintained at the Mallinckrodt Institute of Radiology in St Louis, Mo. Standard demographic topics covered in each year's questionnaire include staffing of resident teaching services by faculty, resident numbers and gender distribution, and salaries and benefits. Other topics are addressed only periodically. Every 4 years, the questionnaire includes a set of questions on the chief resident year, the number of chief residents or co–chief residents, the method of selection, and the chief resident's responsibilities and extra benefits.
The 2000 survey (5) indicated that chief residents in 2000 were more involved in organizing preparation for ABR examinations, had more office facilities, and had more administrative duties than did chief residents in 1996 (11). Although most who responded were in their 4th year of training, there was an increase among respondents in the percentage of 3rd-year chief residents, from 38% to 41%. There was little change in responsibilities, with 70%–90% organizing the curriculum and schedules for clinical rotations, vacations, and call. A smaller percentage (50%–65%) participated in resident selection, resident teaching, and student teaching, and 55% also organized social functions. The increase in administrative responsibilities was perceived to result from increased clinical demands on faculty time.
The 2000 survey also reviewed chief resident benefits. Seventy-three percent received a financial bonus ranging from $200 to $6,000 (average, $1,475). Eighty-five percent went to an additional meeting, usually the A3CR2 annual meeting. The percentage of respondents with office space increased from 28% to 48% (5). Although the A3CR2 survey provides useful information for consideration, it should be noted that the response rate is low (35%) and that there is tremendous variation among training programs as to size and complexity.
Disadvantages of Chief Residency
Before the many rewards of chief residency are considered, a few disadvantages need to be addressed. Some residents may not be interested in the position and consequently would be unhappy with the responsibilities and would perform less than optimally. The added administrative responsibilities can distract the chief resident from academic studies and research interests. Some may lack the interpersonal skill and diplomacy essential for success. Although this attitude may be difficult for a program chairman to recognize, some residents are unhappy with the program and do not believe they can contribute much to it. It also takes a special personality to cope with the added frustrations and conflicts while having only limited authority to react (4, 6).
Rewards of Chief Residency
In contrast to the few disadvantages, the rewards of chief residency are many. It definitely is an experience in leadership and a good assessment of one's interest in and aptitude for future professional leadership positions in academic or community practice. Whitman Associates, Salt Lake City, Utah, offers an annual “Chief Resident as Manager” course. More than 4,500 residents have participated in this course since it began in 1987. The course is designed to help new chief residents manage the administrative responsibilities delegated to them. Its topics include improving communication skills, managing time, making meetings productive, balancing professional and personal goals, giving feedback, delegating work, motivating others, and building a team. If performed successfully, the chief residency may lead to future opportunities for group leadership. In any event, it can be counted as a valuable experience and so noted on a curriculum vitae or résumé.
Chief residents are asked to participate in other activities, as well. House staff organizations are maintained at each institution. Attendance at the A3CR2 annual meeting, held in conjunction with meetings of the Association of University Radiologists and affiliated societies such as APDR, is a perquisite of both incoming and outgoing chief residents in most departments, and more than 200 chief residents typically attend. The organization retains its original name referring to academic chief residents even though membership was expanded to include chief residents from nonuniversity programs years ago, when similar changes were made in the sponsoring organization, the Society of Chairmen of Academic Radiology Departments. The descriptor academic remains appropriate because all training programs carry out an academic mission, whether within or without a sponsoring university.
A3CR2 was founded by Malcolm Jones, then a senior faculty member at the University of California, San Francisco (12). Twenty-two chief residents attended the first meeting in 1969 at Berkeley, Calif, which preceded the annual meeting of the Society of Chairmen of Academic Radiology Departments. Commercial sponsorship from General Electric, Eastman Kodak, and DuPont assisted in establishing the programming that is now maintained by registration fees and the generosity of each chief resident's department. Image interpretation panels were a component of programming from the beginning. Other sessions included reports on organized radiology proceedings that resident representatives attended. The problem-solving sessions continue to provide an opportunity for small-group discussions among residents of various programs on issues regarding resident training and practice. Results of these sessions are reported to APDR for future consideration. Some of these discussions have resulted in policy changes, such as maternity/paternity leave, and scheduling of the ABR written examination earlier in residency than previously established. With limited time for unique programming during the annual meeting, the steering committee has decided to replace one of the image interpretation panels with a tutorial session on a subject of interest to the entire group. Basic and advanced cardiac imaging tutorials were presented in 2001 and 2002. There are also guest lectures, conjoint panel presentations, and informational breakfast sessions with the American College of Radiology (ACR), the ABR, and the APDR.
Incoming chief residents attending the last business session of the A3CR2 annual meeting have the opportunity to be selected, by lottery, to the next year's steering committee. This committee runs the organization during that year and includes a chair and secretary, session leaders for the next annual meeting, and representatives to meetings of other radiologic organizations. During 2002, representatives from A3CR2 attended meetings of the ACR and its resident physician section, the ACR summer conference, the American Medical Association resident physician section, the American Association of Physicists in Medicine committee on the physics examination, and the Society of Computer Applications in Radiology resident roundtable. In addition, the steering committee meets at the RSNA scientific assembly to plan the upcoming spring meeting.
Other, less common rewards of chief residency include financial supplements, decreased call responsibilities compared with other residents, office space, and secretarial support. Above all, however, there should be the satisfaction of a job well done.
References
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- Report of the Accreditation Council for Graduate Medical Education Work Group on Resident Duty Hours. Available at: www.acgme.org/DutyHours/wkgroupreport611.pdf. Accessed June 25, 2002.
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PII: S1076-6332(03)80151-4
doi:10.1016/S1076-6332(03)80151-4
© 2003 Acad Radiol. Published by Elsevier Inc. All rights reserved.
