The role of a residency training director (TD) is multifaceted, often encompassing the responsibilities of an educator, administrator, mentor, role model, facilitator, clinician, and researcher (1). Effective July 2007, the ACGME Residency Review Committee (RRC) for psychiatry acknowledged for the first time the role of an associate training director (ATD) to assist the TD in administrative and clinical oversight of the educational program (2). Although the RRC has established minimum time-commitments for the position, based on the size of the program, the precise role of the ATD has been left undefined, allowing institutions the flexibility to craft these positions according to their unique needs. A small number of studies have focused on the characteristics and job satisfaction of TDs across other disciplines (1, 3–5); however, no studies have specifically focused on the role of ATDs. In this study, a survey of ATDs in psychiatry was conducted to further understand how ATD positions are structured, to elucidate some of the challenges faced by ATDs, and to identify key principles for creating successful ATD positions.

ATDs in psychiatry across the United States were identified from 2008 and 2009 membership lists maintained by AADPRT. An additional e-mail was sent out to the AADPRT list-serve, asking TDs to provide contact information of any ATDs working with them who were not members of AADPRT. Responses indicating an undeliverable e-mail address, despite efforts to confirm accuracy, were excluded in addition to those indicating they had been inappropriately identified as an ATD.

Survey questions were derived from the literature regarding job satisfaction in medical settings (6) and non-medical industries (7), as well as through ATD caucuses held during the annual meeting of AADPRT. Information regarding demographics, professional activities, job satisfaction, and career goals was elicited through 27 multiple-choice questions and responses on a 5-point Likert-scale to 17 statements. Through two open-ended questions, respondents were also asked to comment on the best aspects or favorite parts of their job, in addition to the worst, or least-favorite, aspects of their job.

The survey was developed through a secure web-based program at the University of Texas Southwestern Medical Center. An e-mail was sent to each ATD in May 2009 to explain the goals of the study and provide a hypertext link to gain access to the voluntary survey. A reminder e-mail was sent 2 weeks after the initial e-mail, for a total of two requests. All responses were anonymous.

Descriptive statistics were used to analyze demographic data. Response categories for variables were combined when particular responses were rarely selected. Mean Likert scores were used to account for missing data on items regarding job satisfaction and career goals. Likert responses were then collapsed into two categories: Strongly Agree/Agree versus Neutral/Disagree/Strongly Disagree.

Qualitative techniques adapted from content analysis were used to review narrative responses to open-ended questions for recurring themes and ideas. Two investigators independently coded all comments. Theme-specific groupings and detailed summaries were then established by consensus.

The study was approved by Institutional Review Boards at the New York State Psychiatric Institute and University of Miami. The Institutional Review Boards at the University of Texas Southwestern Medical Center and Stanford University made the determination that this project was exempt from human subjects review.

Demographics and Professional Activities

Of 170 ATDs surveyed, 73 (42.9%) completed the survey. Approximately 69.9% of respondents held the position of associate training director, and 30.1% were designated as assistant training director. Most respondents reported that they have been in their ATD position for 3 years or less (71.3%); 34% indicated that they were the first person to fill an ATD position within their department. Demographic data are summarized in Table 1.

Among a list of 12 potential activities, more than 80% of respondents indicated that they were involved in each of the following: reviewing and interviewing applicants, resident supervision, teaching didactics, curriculum development, residency policy-development, reviewing evaluations, and discipline and remediation of deficient residents. ATD responsibilities were often organized by focusing on specific residency years (22.2%); training on a clinical service (37.5%); and/or around specific administrative areas, such as evaluations, resident-selection, or didactics (51.4%). Many indicated that their job included some combination or overlap of these broad categories (27.4%). A few ATDs (15.1%) noted that there was no clear division of duties between their role as an ATD and the TD and/or that they were involved in essentially all tasks of training. In addition to duties related to the task of an ATD, responders were also involved in direct patient care (90.4%), other administrative roles (71.2%), and/or research (46.6%).

Job Satisfaction and Career Goals

Overall, 75.3% of respondents were happy with their experience. The majority of ATDs endorsed feeling supported by faculty (75.3%), administration (72.6%), and the TD (85.7%) and reported that they were encouraged to participate in major program decisions (76.7%). Also, 75.3% of ATD respondents felt they had adequate independence to initiate worthy projects within the program. Approximately half (56.2%) agreed that they had adequate authority to fulfill their duties.

Fifty-five individuals also provided narrative responses regarding the positive aspects of their jobs. Educational activities with residents (including teaching, supervision, and mentorship) or general comments about working with residents were included in 73% of responses. ATDs also cited relationships with the TD, faculty, and staff as rewarding. Other job responsibilities (such as applicant-recruitment) or inherent qualities of the ATD position (such as independence and variety) were included. ATDs also noted the opportunity to combine the ATD role with other non-ATD activities, such as research or clinical care as another positive aspect of the position.

However, some components of an ATD’s work-life were viewed less positively. Approximately half (53.4%) agreed that time allocated for their ATD role was adequate, and 42.4% agreed that the financial compensation was adequate. Only 29.2% agreed that the expectations for the position had been spelled out clearly in advance. Although 47.9% felt that they were able to perform scholarly work in education, only 12.4% agreed that they had adequate time allocated for this work. Sixteen respondents (21.9%) reported that they did not have a mentor. Many (58.9%) indicated that they felt overly stressed by the various demands of their professional life.

In open-ended responses (N=54), ATDs frequently cited bureaucracy as their least-favorite aspect of the position (28%). Other unsatisfying aspects of the job included a lack of time or authority, multi-tasking, and feeling underutilized. A lack of adequate financial compensation and a lack of clear expectations were reported as problematic. Also, several ATDs felt that they did not have adequate mentorship. Handling resident problems and disciplinary issues were among the least-favorite tasks noted by ATDs (22%).

With regard to career goals, 75% of respondents reported that they intend to continue with a career in resident education and administration indefinitely. A similar majority, 74.0%, agreed that it was important that they advance in academic rank. Approximately half (47.9%) reported they were satisfied with being an ATD and were not interested in becoming a TD.

Although ATDs are involved in multiple aspects of resident education, most have little time (≤25%) allocated to the position. Like TDs across other disciplines (1, 5), ATDs in psychiatry find that protected time for research and scholarly work is at a premium. Similar to other clinician-educators (8), ATD roles are often poorly defined and need clarification. All of these factors, combined with a lack of mentorship, could translate into limited opportunities for growth or success (9).

Bureaucracy, a lack of support, and a lack of time or compensation for doing the job were among those items cited by ATDs as their least-favorite aspects. These factors may directly influence job turnover. Low satisfaction with colleague relationships, a high percentage of administrative work-time, and a lack of formal training in dealing with problem residents were independently associated with job turnover among TDs in internal medicine (3). Likewise, “administrative hassles” were the single most common reason for considering a job change among TDs in obstetrics and gynecology (4).

Although there are no national data tracking turnover among ATDs, the majority of ATDs surveyed were in their current position for 3 years or less (71.3%). The high percentage of unseasoned ATDs may be in part due to the relatively new guidelines regarding the establishment of ATD positions in psychiatry (2). However, these data may also suggest relatively high turnover in ATD positions.

Surprisingly, despite the many challenges of the position, the majority of ATDs reported they are happy with their job and intend to remain in education and administration. This may be related to the similarly high rates of ATDs reporting opportunities to participate in major program-policy decisions and to initiate projects within the program. An opportunity to influence the work environment and participate in decision-making has been identified as the single most important predictor of physician satisfaction (6).

A weakness of this study includes the potential for selection bias that is difficult to assess because of the low response rate. Fewer than half of the ATDs surveyed are represented in these results. With regard to the programs represented in this survey, it is not known whether the 73 ATDs who responded to the survey represent 73 programs or fewer, as many ATDs indicated that their program has more than one ATD (34.2%).

Despite these limitations, this study attempts to address a significant gap in the literature regarding the roles and responsibilities of associate/assistant program directors as well as perceptions regarding job satisfaction.

The role of ATD can be a valuable addition to the training program’s architecture. The ATD’s chance of success in the position could be enhanced by careful attention to the structure of the position (including clear delineation of duties, protected time for academic projects, and the availability of mentorship). The ATD’s ongoing growth as a psychiatrist, direct contact with residents, and a plan for academic advancement with leadership training and support (10, 11) are important elements of this success. Practical guidelines for ATD positions, similar to those outlined for TDs (12), may benefit ATDs, TDs, residents, and the institution, as a whole.

The authors express gratitude to Lucille Meinsler and AADPRT, and thank Claire Pouncey, M.D., Ph.D. for her input during the survey development.

At the time of submission, the authors report no competing interests.