Two articles published in this issue of Academic Psychiatry make useful additions to the literature on the role of chief residents in psychiatry education. In this commentary, we set out to place the articles in the context of a review of the existing literature on chief residency in psychiatry training and in medical training in general. We also add our own observations on the developing role of chief residents as informed by our experiences. One of us (J.B.L.) is vice-chair for education of an academic department of psychiatry and a longtime associate training director of a general psychiatry training program, while the other (P.N.) is currently a chief resident in that program.
In 2003, Khurshid et al. (1) surveyed 102 chief residents in psychiatry who attended a chief residents executive leadership program at the Institute of Psychiatric Services in Boston, Mass., to elicit their opinions about various aspects of psychotherapy competency determination, its impact on psychiatry residency programs, and how this decision had been translated into actual practice. This exploratory study noted a wide variation in patient requirements for each area of psychotherapy for competency determination. Also, 54% of chief residents who responded to the survey reported a positive impact of competency determination on residency programs, while 46% of respondents thought that competency determination was a burden. Twenty-seven percent of respondents reported having no specific reading materials for psychotherapy competencies. The study concluded, “…at least in the eyes of the chief residents, there is no consistent standard of integration of competencies into residency curricula” (1).
Young et al. (2) surveyed physical medicine and rehabilitation programs nationally during the 1990–1991 academic year to determine chief resident number, selection method, responsibilities, duration of service, and postresidency destiny. Sixty-two of the 72 chief residents responded with completed questionnaires (86% response rate). Ninety percent of programs had one to three chief residents per year. The most common methods of chief resident selection were by faculty vote (45%), combined resident-faculty vote (22%), and other (33%). The prevalence of administrative responsibilities included orienting new residents (97%), formulating call schedules (92%), dispute mediation (88%), medical student residency interviews (87%), rotation schedule configuration (64%), faculty meeting participation (61%), social event promotion (59%), and elective and externship schedule development (31%). Educational duties included teaching and organizing didactics (87%), organizing pharmaceutical and rehabilitation equipment in-services (77%), arranging didactics (77%), board review coordination (72%), arranging grand round speakers (66%), core curriculum lectures (61%), and facilitating resident research (37%). Chief resident career goals included group practice (48%), academic faculty (29%), solo practice (5%), and fellowship (18%). Young et al. note that as residency programs have grown, chief residents have been challenged by increasing administrative responsibilities and have perceived decreased independence and an erosion of their role as teachers.
To examine internal medicine chief residents’ self-perceived medicolegal knowledge, their exposure to legal medicine in residency, and their attitudes about legal medicine, Kollas (3) distributed a survey to internal medicine chief residents from half (205) of the internal medicine residency programs in the United States. Ninety-two percent of responding chief residents agreed that medicolegal issues played an important role in medical practice but only 28% felt that their programs trained them adequately about these issues. Internal chief medicine residents (greater than or equal to 50%) understood only eight of 19 medicolegal issues examined in the study and they particularly lacked knowledge about the legal issues involved in the business of medical practice. Importantly, the study confirmed that legal medicine instruction improves residents’ medicolegal knowledge. The study was limited by the fact that residents’ self-perceived awareness was used to measure their medicolegal knowledge.
Alpert et al. (4) surveyed pediatric residents and chief residents from 12 different groups (based on geography and program size) to examine whether completion of a chief residency was a predictor of a leadership career in medicine. After being presented with two definitions of leadership, respondents were asked if they agreed with the statement, “I am a leader in my profession.” There were 475 respondents from a total resident sample of 963 for a response rate of 52%. More former chief residents compared with non-chief residents (75% versus 64%), more former fellows than nonfellows (75% versus 60%), and more men than women (74% versus 55%) reported that they were professional leaders. The authors point out that an important limitation to their study was that they relied on a subjective and limited definition of leadership that depended on self-reporting.
Hearney and Razavi (5) hypothesized that the most prevalent personality type for chief residents would be in discordance with the most prevalent type (sensor) in the general population. To test this hypothesis, they distributed a survey based on Jung’s psychological types (thinker, feeler, intuitor, and sensor) to 400 chief residents in internal medicine at the annual National Association of Program Directors in Internal Medicine. Of the 103 surveys returned, overall self-report of communication style revealed the majority (45.6%) to be “feelers” in contrast to the general population, where the most prevalent style is that of sensor.
Peterson et al. (6) reported the results of the 2004 Survey of the American Association of Academic Chief Residents in Radiology. Eighty-five percent of chief residents responded that the new ACGME work requirements had improved their call experience, and 90% responded that their educational experience had been enhanced. Sixty percent of programs had incorporated a night float system into their rotation schedule as an alternative to the traditional night call system. This reflected an increase from 44% in 2000. In 43% of programs surveyed, chief residents were elected by their peers. In another 28%, they were chosen by the program director, by staff in 22% of programs, and by the department chairperson in 5%.
Espat et al. (7) analyzed chief resident-reported gastric surgery experience by reviewing the Resident Statistical Summaries from 1990 to 2001. They found that although specific gastric procedures performed by chief residents may have markedly increased or decreased overall, gastric surgical experience remained relatively constant over the 12 years studied. While vagotomy disappeared, there was an explosive increase in the number of gastric-reduction procedures. Moreover, laparoscopic gastric resection procedures were not a contributory component of the chief residents’ case experience, and the average chief resident only reported approximately two gastrostomy procedures over the decade reviewed.
In 2005, Horwitz et al. (8) surveyed chief residents in internal medicine from 324 programs outside of New York to evaluate national changes in internal medicine residents’ clinical and didactic experiences after the institution of work hour regulations. Eighty percent of chief residents reported that their programs had changed their schedules to comply with work hour rules. Most programs (72%) reported no change in average patient load per intern after work hour regulations. Many programs (48%) redistributed house staff admissions though the call cycle. The number of admissions per intern on long call decreased in 31% of programs, and the number of admissions on other days increased in 21% of programs. Forty-eight percent of programs added a float rotation after work hour regulations. Residents on outpatient rotations were given new ward responsibilities in 36% of programs. Third-year resident ward and float time increased in 34% of programs, while third-year elective time decreased in 22% of programs. The mean weekly hours allotted to educational activities did not change significantly, but 56% of programs reported a decrease in intern attendance at educational activities. The authors conclude that in response to work hour regulation, many internal medicine programs redistributed rather than reduced residents’ inpatient clinical experience.
The thoughtful theoretical paper by Ivany and Hurt (9), published in this issue, characterizes the role of the psychiatric chief resident as that of both a “legislative leader” and a “representative leader” of the residents. This characterization emphasizes dual roles of the chief resident: on the one hand, the chief resident leads a cohort of residents through example and exhortation as a legislative leader who has very little real executive power; on the other hand, the chief resident acts as the representative of the resident cohort to the training director and teaching faculty of a training program. The authors contend that the effectiveness of a chief resident in these dual roles is maximized by a system of choosing chief residents which involves both the residents and faculty. The authors assert that a chief resident is empowered by the credibility that a joint selection process by the residents and faculty provides, making the chief a more effective leader by example of the residents and a more effective representative of the residents to the faculty. The authors also state that the continuity and stability provided by a year-long term as chief resident maximizes the likelihood of the chief being an effective leader and representative. They also emphasize the importance of an academic faculty’s inclusion of the chief resident in decision-making in all areas of a department’s functioning which have an impact on the day-to-day lives of the residents.
The second paper published in this issue, written by Warner et al. (10), presents the results of a survey of outgoing chief residents in psychiatry on the nature of their experiences in their respective training programs, their reflections on those experiences, and the leadership qualities common to effective chief residents. Among the findings of the survey was the wide range of methods of selection of chief residents employed by training programs throughout the United States. Nearly two-thirds of respondents indicated that resident input was considered in their selection as chief, and nearly two-thirds reported that the program director or training committee made the final choice; but 34% reported that they had been chosen by faculty members alone. The chief residents surveyed reported that they felt their greatest personal strengths included leadership skills, communication skills, compassion, and organizational skills. The respondents most often named integrity, dependability, and initiative as their most important leadership traits, and the majority described their leadership style as a “participatory style,” as opposed to a “selling style,” “delegating style,” or “telling style.”
The two new papers published in this issue, taken together, have important messages to impart to psychiatry training directors and their chief residents on the nature of designing chief residencies to maximize the effectiveness of the chiefs. We agree that a joint selection process involving both residents and the training director enhances the likelihood of a chief resident having the credibility with residents to allow effective representation of their points of view, while at the same time making a good fit with the training director. A chief resident must walk a fine line in effectively representing the interests of residents, who are understandably concerned with getting the best clinical and didactic training possible under humane working conditions, while understanding the sometimes competing needs of a training program in shifting residents’ rotations to fit the clinical needs of affiliated training hospitals and clinics, for example. In our experience, a term of service of a full year for a chief resident or co-chief residents is also important; a shorter term of service is likely to deprive both the residents and the training program of the stability which a full year in office allows.
The psychiatric chief residency is an important role, ideally allowing improved communication and cooperation between residents in training and the faculty in their training programs. We hope that future studies continue to explore the subject of how to maximize the effectiveness of chief residents in carrying out their role in psychiatry training.