Program Directors as Conflict Managers
Article Outline
- Managing Resistance to Change
- Quality Improvement
- Misunderstandings
- Senioritis
- Moonlighting
- Curricula, Evaluations, and Other Input
- Personality Issues
- Explaining Conflicts with Different Models
- Preventing or Alleviating Undue Stress
- Faculty Conflicts with the PD
- Other Morale Killers from the Staff
- Sexual Harassment
- Substance Abuse and Psychiatric Problems
- Conflicts with the Chairperson
- Conflicts Resulting from a Shortage of Faculty
- Conflicts with Non–Radiology Staff Members
- References
- Copyright
One possible reason for the reported 16.58% turnover in radiology program directors between July 1, 2001, and June 30, 2002 (1), is the numerous conflicts that the program director (PD) must handle. Conflicts occur between faculty and residents, residents and other residents or fellows, PDs and chairpersons, PDs and faculty, residents and technologists or other hospital employees, residents and nonradiology faculty, and PDs and administrators of the institution. At times, PDs may feel powerless to successfully manage these conflicts. This article reviews the types of conflicts that can occur in a radiology residency program and the ways in which PDs can intervene to prevent them or resolve the problems that result from them.
Managing Resistance to Change
If the PD wants to initiate changes, the changes should first be discussed with the staff and the residents. It is wise not to make many alterations within a single year if even a minority of the residents or staff could perceive them negatively. What the PD sees as a positive change may not be understood as such by others. One example would be an increased number of lectures, especially if scheduled in the evening or early in the morning. The residents may value time at home (and sleep) more than another lecture. Another example would be an increase in the number of conferences devoted to the new Accreditation Council for Graduate Medical Education (ACGME) core curricula and to the development of “noninterpretive skills” (professionalism, communication, becoming a lifelong learner, and learning how to interpret the radiology literature). Residents may resist the addition of such topics to the curriculum, fearing a dilution of its academic substance. Pointing out the new ACGME requirement may be less effective in convincing residents of the value of such conferences than pointing out that the American Board of Radiology (ABR) will be testing them on these subjects.
It is best to discuss why and how changes are to be made, before implementing them. It is also usually best to ask for feedback on a new idea before presenting it as a change in policy. If a firestorm of protest results from a proposed alteration on a minor issue, it may be wise to acquiesce and not dissipate goodwill. The PD should be the most knowledgeable faculty person regarding residency matters, but even he or she has no monopoly on truth.
Quality Improvement
Conflicts in residency programs are inevitable, but many can be avoided when a system for continuous monitoring of the program is followed. The quality improvement process must include an internal review of the program midway between ACGME site visits and yearly confidential critiques of the program and each faculty member by the residents. At the Baptist Medical Center in Oklahoma City, Okla, the anonymity of residents evaluating faculty is assured by having residents give their reviews to the residency coordinator or to a resident who submits a batch of evaluations to the coordinator. The evaluations are then typed, and the originals are either destroyed or made inaccessible to staff who might recognize the handwriting. The PD reads all the evaluations, the faculty sees all program reviews, and each faculty member sees his or her own performance reviews. Faculty members who receive poor evaluations are counseled by a senior member of the group, such as the president.
Hartman (2) recommends that at least two faculty members and two residents complete a lengthy questionnaire that he has devised, related to institutional requirements, and another questionnaire related to program requirements, in preparation for internal program review. At the Baptist Medical Center, an external review is conducted more than a year before the ACGME site visit. An external review is best conducted by an expert, such as a former site surveyor for the ACGME or a former member of the residency review committee for diagnostic radiology. It gives residents another opportunity to talk about their concerns with someone from another institution who may have creative suggestions for improvement.
Other ways of maintaining ongoing communication between residents and the PD include soliciting comments with an idea box, meeting regularly with residents as a group, and including chief residents in regular faculty meetings. The ACGME requires regular conferences between individual residents and the PD to discuss resident performance, which gives residents the opportunity to voice any concerns they have about the program. Residents can also participate in periodic meetings of technologists, transcriptionists, and file room personnel to talk about issues of mutual concern. Residents must be represented on the sponsoring institution's graduate medical education committee, which provides an opportunity for them to participate in the oversight of all residency programs sponsored by the institution. It is frustrating for a PD to hear residents' complaints secondhand from a site visitor, when residents have been given opportunities to discuss issues with the PD. Such complaints undermine faith in the quality improvement process, the PD, and the program.
Misunderstandings
Misunderstandings can arise between the PD and residents who act contrary to residency program policy. Examples include a resident who moonlights during the residency workday while other residents cover for him or her, one who moonlights or vacations during sick time, and one who “forgets” to obtain advance approval for vacation time and is inexplicably absent (an absence that is explained when the resident is called on his or her cell phone and discovered to be traveling in another state). The PD may be called down by a vice-president to explain a claim from cafeteria workers that a resident took a loaf of bread, a whole cake, or dinner for a colleague as part of a complimentary on-call meal. The PD may have to explain why a resident claimed diapers as grocery expenses while on rotation at the Armed Forces Institute of Pathology. Because of such incidents, an institution may decide not to reimburse residents for expenses in future. Each incident has an effect on the program and the rules put in place for future residents.
Conflicts also can occur when a resident follows advice from another resident that runs contrary to the explicit policy in the residency manual. Such behavior can result in a “hidden curriculum” that undermines the uniform implementation of regulations and leads to perceptions of favoritism and to various other misunderstandings. When residents are allowed to violate written policies—whether because they were not informed of the policies or because they were assured by others that the policies did not have to be followed—those policies become ineffective.
It is helpful to have a detailed residency manual that is distributed to all residents and faculty, so that all members of the training program will understand what is expected of them. This handbook should be distributed at the beginning of the academic year and updated annually. Evaluation forms should be included so that residents will understand and anticipate the evaluation process. Residents should be told that they are responsible for reading and following the policies outlined in the manual. This process can help prevent charges of favoritism against the PD when residents ask for exceptions after they have acted out of accord with written policies. For example, if a resident purchases airline tickets before obtaining approval for vacation time and then is told that all the vacation slots are taken, the PD can show the resident the vacation policy that is clearly outlined in the manual. How such an incident is handled will depend on the philosophy of the department, PD, and residents; but at the very least, the PD can emphasize to residents that this particular behavior will not be acceptable in the future. If residents have an opportunity to help shape policies, there will be fewer misunderstandings when policy infractions occur.
Senioritis
Senioritis is a term used by some PDs and other teaching faculty to describe the change in behavior of residents during their senior year of residency. Specifically, it refers to senior residents being less available to provide service within the department. The main reason for this change is that senior residents have to spend time preparing for the ABR examination. Some programs condone this behavior as a resident recruitment tool because they are competing with other programs that allow it. When this behavior occurs year after year, even if it is only part of the hidden curriculum and not approved as program policy, it is viewed by residents as acceptable and even as an entitlement.
Recently, the ABR has allowed residents to take the physics part of the written test earlier, hoping to relieve the tremendous pressure on residents in their final year. This new policy, however, may simply lead to an earlier onset of “senioritis.” Each program must decide what is reasonable regarding ABR examination preparation. Residents need to feel that they are working in a supportive environment. Frequent communication between the PD and residents can help foster an attitude of responsibility among residents.
Senior residents often have fewer call responsibilities than junior residents, which allows them more time to study. This means that the department has a disproportionate number of less experienced residents available for call, which can lead to complaints from physicians outside the department. PDs can approach this problem by developing a call schedule that addresses both service and educational needs, with guidance from both faculty and residents.
Residents should be counseled early in residency about the importance of studying on a consistent schedule so that they do not end up cramming for the ABR examinations. They must be told to be aggressive in their own education (3). The American College of Radiology in-training examination, the Radiological Physics examination (RAPHEX), and faculty evaluations of residents should help identify problems with residents by the end of the 1st year of training. Unfortunately, a self-defeating cycle may have been established by then (4) in which the resident does poorly during conferences and on rotations, has a negative view of his or her ability, and spends too much time and energy worrying or blaming others rather than studying. Such residents may need to study differently—for example, by using a “test–study–test” book format, teaching files, or Web-based learning, or by participating in group study sessions. Some residents merely need to study more. When residents perform well, they receive approval from staff and peers and begin to develop confidence and greater enthusiasm for studying. The PD may need to offer tips to residents on how to study and manage time efficiently.
Moonlighting
Many residents are deeply in debt (5). They may be supporting a family with young children. Some residents want a better lifestyle than they were allowed during medical school (6). Some appear to make unreasonable financial choices, saving little because of a failure to budget, indebtedness, high projected income growth, or poor financial management (7). These factors, as well as a desire to experience practicing independently in a private practice environment, motivate residents to moonlight. Residents who moonlight may be tired during clinical rotations and may not have enough time for research or studying, all of which can lead to conflicts among residents and between residents and faculty.
It is important that the program have a policy regarding moonlighting and that residents fully understand it. The policy should be developed with guidance from faculty and residents and reviewed regularly (eg, annually) to make sure that it continues to address the needs of residents and the program. PDs can discuss the effects of moonlighting with residents during the biannual resident review process. The effects of moonlighting on the residency program will depend on how many residents moonlight. The PD should closely monitor the effects on individual residents, as well as on the program. The program's policy must be in accordance with the ACGME institutional policy:
All sponsoring institutions must have a written policy that addresses professional activities outside the educational program to include moonlighting. The policy must specify that residents must not be required to engage in “moonlighting.” All residents engaged in moonlighting must be licensed for unsupervised medical practice in the state where the moonlighting occurs. It is the responsibility of the institution hiring the resident to moonlight to determine whether such licensure is in place, whether adequate liability coverage is provided, and whether the resident has the appropriate training and skills to carry out assigned duties. The sponsoring institution must ensure that the PD acknowledges in writing that she/he is aware that the resident is moonlighting, and that this information is made part of the resident's folder (8).
The PD should try to make sure that residents have adequate vacation time, time off after night call, and a night call schedule that is not overly frequent. Reasonable schedules are more likely to allow residents who are doing well to do some minimal moonlighting in a way that does not interfere with their residency responsibilities.
Curricula, Evaluations, and Other Input
One way to help residents succeed is to provide them with clearly defined curricula, such as those described by Collins (9) and others (10, 11, 12). The Association of Program Directors in Radiology (APDR) has curricula on its Web site from multiple sources, but the PD should update the curricula annually and individualize them for his or her own program and for each month, rotation, and institution. One way to limit conflicts regarding resident performance is to provide residents and faculty with clearly defined expectations. Residents should be encouraged to ask the staff what is expected early in the rotation and to ask how they are doing. They should not wait until the written evaluation for this information, and the staff should not wait until then to communicate how the resident is performing.
A potential problem with evaluations is that a staff member who wants to be popular with all the residents may be very complimentary to residents openly and in their evaluations but quite critical in private. It is difficult for the PD to explain why a resident's behavior or study habits should change when the resident has received excellent oral feedback and written evaluations. Residency evaluations have the potential to do tremendous good. They can reinforce good behavior, suggest areas for improvement, raise morale, and increase self-confidence. They can also do enormous harm. They can diminish a resident's self-image and discourage any effort to improve. Therefore, they should be done with care, should be as accurate as possible, and should be done reasonably often (13).
It can be difficult for a PD to decide whether to officially record individual residents' misconduct in case of potential legal action, as such records could hurt the residents later. Some directors keep separate files on incidents of resident misconduct so that if improvement occurs it will not be necessary to include the negative information in the resident's permanent file. Some directors are also very reluctant to put a resident on probation because that action becomes a part of the permanent record and will follow the resident around every time he or she applies for a license or hospital privileges.
It is generally understood that unless extraordinary things happen and the resident cannot learn appropriately or make necessary changes, or the resident decides to move for personal reasons, he or she will stay in the radiology residency program for the duration. This implicit understanding goes beyond the typical 1-year contract and institutional policies for dismissal, and it can create difficulty in the case of a resident with intractable problems. One person, especially in a small or medium-sized residency, can damage morale and take an inordinate amount of the PD's time. However, the dismissal of a resident before the completion of residency can also create morale problems and may be remembered by other residents for years to come (so-called institutional memory). Unfortunately, the facts will often be misremembered or distorted.
Personality Issues
The most difficult problems to deal with are interpersonal conflicts. Some people have difficulty seeing a problem from any vantage point but their own. Some have a temper and are not always understanding or gracious. Some cannot accept responsibility, and blame others instead. Residents who are not doing well may blame their problems on poor teaching or supervision, staff who want them to fail, or the unfairness of the program, even though few others make such complaints. Someone who constantly has disputes with others needs to look at his or her part in the conflicts. A selfish resident or staff member undermines morale and makes it difficult for the department to act as a coherent team. When counseling by the PD is unsuccessful, outside help from a counselor or other mediator may be necessary to help resolve conflicts arising from interpersonal problems.
One way to foster positive interactions among residents, faculty, and support personnel is to engage residents in role playing. Topics can address real-life issues within the program, such as disputes over maternity leave or over the work expected of pregnant residents. Role playing gives residents some practice in communication skills and being sensitive to others.
Effective communicators know how to deal with angry individuals. McCue (14) gives the following tips: (a) never lose your cool; (b) keep your distance and do not touch; (c) do not comment on the other person's anger; (d) speak first, if possible—you will set the tone for communication; (e) listen to the outburst without interrupting; (f) empathize by paraphrasing the other's concerns; (g) control the dialogue by asking thoughtful questions; (h) conclude with an assurance that something will be done.
Occasionally a resident will say something insensitive in front of a patient or will not be gentle or understanding enough. The PD may be asked to settle disputes that arise from such interactions, which may be difficult to do if there are no independent witnesses. The PD must listen to the resident and demonstrate concern both for the resident and for the other parties involved. While a resident who has difficulty with interpersonal interactions needs to be counseled, the PD should be careful about assigning blame on the basis of hearsay.
When a resident does not get the desired administrative answer from the PD, he or she may seek out another staff member for support rather than going through the proper channels. This may occur if there is not a bond of trust between the resident and PD. If a resident does not agree with a PD's decision, he or she should be able to bring the matter to the residency committee or use the grievance and appeals process. At the Baptist Medical Center, a resident can appeal a residency program committee's decision by pleading the case to a group of two faculty members and one resident, none of whom are on the committee.
Other conflicts involve sick leave and other discretionary time off. Some men complain about maternity leave given to women, the time a new mother spends nursing, or a female resident staying home with a sick child rather than having the father stay home. In one survey of residents and faculty, “the majority acknowledged stress to themselves and their departments yet indicated that pregnancy had a humanizing effect on the work environment” (15). Residency is often stressful, and a natural response to such stress is to focus on fairness. While it is important for residents to feel that their work environment is fair, fair does not always mean “equal.” Open communication between residents and the PD can help prevent feelings of unfairness that stem from a lack of knowledge or understanding of another person's needs.
Explaining Conflicts with Different Models
When people try to look beyond their individual problems, they may see how their personal problems result from a larger, systemic problem. In systems analysis, instead of focusing on blame, one tries to see how the entire system can be improved. Dysfunctional elements of the residency may need to be addressed as a way of approaching individual residents' problems. The functioning of a residency system is in many ways analogous to that of a family. Parents are powerful role models in the way they act and speak to their children. The degree to which parents work hard, read, and take an interest in a child's schoolwork influences the child's attitude toward and approach to learning. Similarly, if staff are perceived to be efficient when there is clinical work to be done in the department, residents working with them may develop similar work habits. Faculty serve as role models in the way they interact with other members of the health care team, participate in scholarly activity, teach, and perform clinical duties.
There are also similarities between a residency program and a healthy community in which people help each other. In a residency, residents vary in how fast they can work, how intelligent they are, and how quickly they can learn. In a healthy residency, residents will assist each other in their work, advise each other, and teach each other in conference, individually, and possibly in study groups.
The performance of a team may be greater or less than the sum of the individual members' skills, depending on the level of cooperation and the quality of the coaching. For residents to feel good about who they are, where they are, and what they do, they must feel they are performing well. The PD functions much as a coach. He or she must make decisions that will, as much as possible, positively affect the team and its individual members.
Preventing or Alleviating Undue Stress
Even before beginning residency, residents may experience the stress and uncertainty of moving to a new location and beginning a training program (16). Any attempt to smooth the transition can be helpful, such as giving residents information on the city and the names of several reputable realtors, providing an outline of goals and objectives for the program and a residency manual, hosting a get-acquainted party, and assigning mentors. Holding periodic meetings with residents to give them information or allow them to ask questions can help reduce tension. Asking for their opinions on policies, educational purchases, or the ranking of prospective residents also can help new residents feel that they are welcome and important members of the team. Frequent feedback is very important, especially early in a resident's career.
Faculty Conflicts with the PD
The PD may have conflicts with other faculty if they do not value the time the PD spends on helping residents or performing related administrative tasks. The problem is exacerbated because most faculty members do not understand the responsibilities of a PD. The APDR recommends that each PD be given the equivalent of a day each week to perform PD responsibilities. Frequent communications between the PD and other faculty will help faculty understand how the PD's time is being used.
The PD may also have conflicts with faculty when they don't teach, don't teach well, or are not perceived as caring for residents. The PD and chairperson can support faculty through feedback from residents, courses on PowerPoint presentations, and the purchase of teaching materials (eg, teaching files and CDs). Another potential conflict between PD and staff arises when fellows detract from the experience of residents and keep them from gaining adequate experience in performing procedures or interpreting radiologic studies. This problem can be prevented if the fellow functions as a teacher and supervises residents doing procedures, but fellows should not do a disproportionate amount of teaching and supervision in place of staff. The PD and fellowship director must work together to ensure that both residents and fellows receive excellent training.
Other Morale Killers from the Staff
To maintain morale, the PD must do much more than provide good conferences, read-out sessions, and supervision. Interpersonal conflicts and inappropriate communications between residents and faculty can damage the morale of all involved in the residency program.
Staff members who make inappropriate comments to one resident about another resident or staff member, or who discuss other staff members or residents in a derogatory manner, can create a negative and sometimes hostile work environment. Resident morale is also affected when residents hear staff complain about the institution or the department. A culture of complaining, negativism, and pessimism is not conducive to a pleasant learning and working environment. Residency and fellowship applicants frequently ask whether residents and staff in the program are happy. Staff can hardly complain if their own residents answer no, when they constantly hear from the attending physicians how bad things are. Finally, residents and fellows are an important source for faculty recruitment, but they will not be attracted to working at the institution after graduation if they hear only the gripes of their mentors.
Morale also can be diminished by faculty members who use humiliation as a tool for teaching. This behavior, which the teachers may have learned from their role models, is perpetuated when taught to residents. The negative cycle that results has been described as “the culture of student abuse in medical school” (17). Residents will feel most comfortable in an environment where they are “recognized by their employers as professionals and by their teachers as colleagues” (18). Other types of abuse reported are sexual harassment and racial or ethnic slurs. Abusive behavior is not limited to faculty actions against residents. Inappropriate behavior also can be seen between residents, technologists, nurses, and other members of the health care team. Incidents of abuse often go unreported; and even when they are reported, they can be difficult to address if there are no witnesses.
Sexual Harassment
Residents, faculty, and other health care workers can be victims, perpetrators, or witnesses of sexual harassment. It is wise to include a lecture on this subject as part of the orientation of new residents. In fact, all members of the health care team can benefit from such a presentation. A little time spent on prevention can prevent a costly untoward outcome. Even the accusation of sexual harassment can be a devastating source of conflict, anger, and humiliation.
Substance Abuse and Psychiatric Problems
Other problems that can affect resident performance include depression and substance abuse among residents and their family members. Al-Anon, an organization that provides counseling and support to family members and close friends of alcoholics, is also useful for the families and friends of those struggling with other addictions (eg, drug addiction, compulsive overeating or gambling, and workaholism). The PD should be sensitive to changes in resident behavior that may indicate a serious problem for which professional counseling or other support may be necessary.
Procedures for dealing with resident substance abuse should be established, including recognition, documentation, referral, treatment, and return to practice. PDs are required to communicate adverse actions against residents to prospective hiring groups and licensing agencies; they “must report disciplinary actions and actions resulting from investigations by state licensing boards or peer review agencies” (19).
Lucy (20) recommends that when there is substantial suspicion of a psychiatric or physical disorder impairing a resident's performance, the resident should be approached and asked to submit to an evaluation by an appropriate physician not already seeing the resident. If the resident does not agree, and the program standards continue not to be met despite warnings, then dismissal can be considered. Lucy also recommends for serious cognitive or noncognitive problems that “three criteria must be met to satisfy Academic Due Process requirements: 1) The resident must be notified in writing of the problem and its potential impact on his/her career, 2) The resident must be given the opportunity to review the concerns and express his/her opinion about those concerns, and 3) The decision to take adverse action must not be arbitrary or capricious” (20).
Conflicts with the Chairperson
The PD may have conflicts with the departmental chairperson when they do not share a common vision for the departmental education enterprise. An educational budget (21) that is developed and approved by a committee of faculty and residents can help ensure agreement on the needs of the program. In university programs, the departmental chairperson should be supportive of teaching and promotion based on educational scholarship. A common complaint is that teaching is taken for granted and research is what really counts in getting ahead. It may help to advise faculty on how to prepare a curriculum vitae that emphasizes teaching. Conflicts with the chairperson or other faculty members also may arise if some radiologists want more residents assigned to their services than the PD believes is warranted. In making these decisions, the PD may be aided by the rotation schedule suggested by the APDR (22).
Conflicts Resulting from a Shortage of Faculty
According to a recent survey, the average university program has about 5.5 unfilled radiology faculty positions (23). This means that there are fewer people to teach and supervise residents. It also means more work for each member of the staff and less time to prepare lectures and teach at the view box or PACS workstation. This situation may make it difficult to meet ACGME regulations, which require a 1:1 ratio of faculty to residents. The problem may get worse. It is estimated that there will be a shortage of 50,000 physicians in the United States by 2010 and a shortage of 200,000 by 2020 (24). Hunter et al (25) commented on a survey showing a decline in academic productivity in the previous 5 years and on a study from the American College of Radiology showing that academic radiologists work more hours per week than nonacademic “full-time post training radiologists.” Arenson et al (26) found that the average clinical workload per full-time–equivalent physician in 20 academic departments increased by 18% between 1996 and 1998. They also found that “none of the departments with high workloads had much NIH funding.” Pressures to publish and to get the clinical work done can conflict with the need to teach residents.
The faculty shortage exacerbates the well-known conflict many institutions experience in trying to balance graduate medical education and patient service (27, 28). This conflict relates to the amount of night call and daytime clinical rotations and how much residents are expected to participate in each. It also relates to the level of resident experience needed for a particular work assignment, the amount of protected time for residents to attend lectures, and the time staff have to teach at the viewing station and in lectures or conferences. In internal medicine, Wartman et al (27) suggested adopting an advisor/mentor arrangement, addressing the professional development of physicians, offering seminars and mini courses with residents participating in the curriculum, and putting in place certain other efficiencies for the resident (eg, devising a faster way to find reports or records and decreasing nonessential resident paging).
A new potential conflict between residents and staff may arise from the shift to more outpatient radiology services. Residents can benefit from rotating through these areas as they assume more of the total case volume, provided there is good teaching and educational value. It has been said, however, that “the greatest value of residents' services for their employing institutions remains in the inpatient setting where they work as inexpensive professional labor, working long and unattractive patient care shifts providing acute care. In the ambulatory setting, they are less efficient, work ordinary hours, and require real time on-site supervision” (19).
Conflicts with Non–Radiology Staff Members
The PD may have to intervene when there are conflicts between residents and non–radiology faculty. These conflicts often result from disputes that occur on call, and it is often difficult to know who is at fault. When people are tired and not pleased at being where they are, minor disputes can become big ones. One problem occurs when a referring physician is unreachable by pager, does not leave an alternative number, and then complains of not being promptly notified of urgent, important, or unexpected findings. This problem wastes the time of residents and sometimes results in poor patient care. Occasionally, non–radiology attending physicians do not want to work with more junior residents, preferring senior residents or faculty. The PD must determine whether this is a general philosophy or whether it arises from specific concerns regarding resident performance. Non–radiology faculty should be assured by the PD that residents are given independence based on their level of training and skill and that any documented deficiencies in their performance will be addressed appropriately.
The PD may have conflicts with the institution's graduate medical education committee for a variety of reasons. One reason might be that the PD is not following ACGME guidelines. When there are few residency programs in an institution, however, it is more likely that the PD knows and cares more about the ACGME requirements than some members of the graduate medical education committee. Conflict also might arise over a failure of the committee to recommend adequate funding for radiology residency training. In institutions with few residency programs, there may not be a dedicated medical education administrator, which could prevent needs specific to medical education from being heard at budget time or during space-planning meetings of the hospital board.
In sum, the life of a PD is filled with difficult conflicts. Some can be settled fairly easily, but others may be beyond the PD's abilities to resolve. Teamwork between the departmental chairperson, the PD, other members of the staff, and the residents is essential to a successful program and a happy department. Despite some heartache and gray hairs, being a PD can be one of the most satisfying, worthwhile, and joyous experiences in academic radiology.
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PII: S1076-6332(03)80154-X
doi:10.1016/S1076-6332(03)80154-X
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