The chief resident position was developed in the late 19th century for “a senior resident who, having demonstrated competence in his craft, was allowed to manage and operate on patients under minimal supervision” (1). Over the next hundred years, the position evolved into an administrative role for preparing junior staff and faculty, and later into a position of leadership integral to the quality of education in a residency program.
The first references to a chief resident in psychiatry were made in the early 1970s when a panel discussion was held at an APA Annual Meeting. Subsequently, a number of point-of-view papers were published by former chief residents, including Sherman (2), who attempted to formulate the role of the chief resident in terms of group memberships and intergroup relationships. In 1974, Grant et al. (3) conducted the first investigation into chief residents in psychiatry by examining the attitudes of five psychiatry training programs towards the position. Their investigation determined that the position was important and noted that chief residents were responsible for advising and influencing both younger, less experienced residents and older faculty members, but were also challenged with balancing the demands and rewards of the position. Additionally, they found that being the chief resident required tolerating uncertain consequences, divided loyalties, and, at times, unsolvable ambiguities (3).
In 1980, Lowy and Thornton (4) noted that there were several inherent problems with the position: poor definition of the role, lack of training for the job, divided loyalties, and unrealistic expectations. They cited several characteristics which they felt were desirable in a chief resident: leadership potential, mediation skills, the ability to direct, and a sense of humor. Additionally, Kessler et al. (5) found that women and men held similar perceptions and attitudes towards the chief resident position.
Unfortunately, few other studies or papers have examined the role of the chief resident in psychiatry since that time (6, 7). APA recognized the importance of this position and developed an executive leadership training program to help train and prepare chief residents and develop future leaders in psychiatry and medicine. The purpose of this study is to examine outgoing chief residents in psychiatry to 1) determine common characteristics between programs, 2) examine the residents’ perspectives on their experiences, and 3) determine their common leadership qualities.
APA provided a copy of its invitation list for the APA/Lilly Chief Residents’ Executive Leadership Program. The list was reduced to only those with valid e-mail addresses and those who had served as a chief resident in the 2004–2005 academic year. Each participant was sent an e-mail informing him or her of the nature of the study and offering the opportunity to participate. Those who chose to participate completed the attached survey and returned it via e-mail. We obtained Institutional Board Review approval for this study.
The survey consisted of 36 questions divided into eight parts: 1) basic demographic information (age, sex, ethnicity, military history, and residency history), 2) position characteristics, 3) method of chief selection, 4) preparation for the position, 5) responsibilities of the position, 6) perceptions of the position, 7) principles of leadership, and 8) effects of the position. The questions were of three varieties: request for specific data, multiple choice, and perception ranked on a 5-point Likert scale. For the multiple-choice questions, respondents were given 1) a list of eight skills and asked to select the two they felt were their greatest strengths, 2) a list of 10 principles of leadership and asked to select the three most important principles to them, and 3) a list of 16 leadership characteristics and asked to select which they viewed as the three most important for an effective leader. Results were entered into an SPSS database and examined for descriptive statistics.
Of the 89 outgoing chief residents in psychiatry contacted, 53 (59.6%) voluntarily chose to participate. The respondents, all from different programs, represented nearly one-third of all of the psychiatry residency programs in the nation for the 2004–2005 academic year. The average age of the participants was 33.5 years. The population was evenly split between the sexes (female=51%, male=49%). The majority of respondents were Caucasian (62.3%) and in their first residency (86.3%). Other races represented were Asian (17%), Hispanic (9.4%), and African American (5.7%). Nearly 40% reported a history of prior leadership experience, and 19% reported a history of military service.
The chief resident position was mainly filled by PGY-3 (20.8%) or PGY-4 (73.6%) residents who spent an average of 9.5 hours (SD=2.084) per week performing their duties. Most served for a term of either 9 to 12 months (66%) or 12 to 18 months (22.6%). Nearly half of the programs represented had two chief residents (45.3%) but a large number had three (22.6%) or one (15.1%). More than half (58.5%) of the respondents had protected administrative/chief time in their schedules, and 56.6% received a stipend for their service. Nearly two-thirds of the chief resident selections were made by either the program director or training committee (staff chosen=34%, staff chosen with resident recommendation=28%, resident elected with staff ratification=23%), while two-thirds of the selection methods also involved some form of resident input (resident elected=11%, resident elected with staff ratification=23%, staff chosen with resident recommendation=28%).
The respondents noted that their greatest strengths were their leadership skills (47%), communication skills (32%), compassion (30%), and organizational skills (30%). The majority described their leadership style as a “participating style” (64.2%) as opposed to a “coaching style” (18.8%), “delegating style” (17%), or “telling style” (0%). They felt the three most important personal leadership traits were integrity (62.3%), dependability (58.5%), and initiative (22.7%).
Table 1 outlines the standard duties and expectations of the chief resident. A majority of the residents reported doing most of the listed duties with the exception of teaching and supervising peers and developing residency rotation schedules.
Table 2 outlines the perceptions that the chief residents had of their experience serving in the position. In general, the respondents were positive about their experience and its impact; however, they were less likely to report getting a clear statement of their responsibilities from their program directors.
Table 3 displays the change in the respondents’ perceived level of comfort with their level of understanding of various aspects of the chief resident position. Respondents noted an increase in their comfort and understanding in all aspects of the skills and understanding. With the exception of supervisory skills, all increases were statistically significant.
The majority (90.6%) said they would choose to perform the chief resident’s duties again. While 88.7% said that this experience had inspired them to seek future leadership opportunities in local organizations, 62.3% stated that they would seek leadership opportunities in national organizations. Additionally, 62.3% stated that they intended to seek positions in psychiatry teaching programs.
Being selected as a chief resident at the culmination of one’s medical training affords many opportunities for personal and professional growth. However, many residents assume the position of chief resident without a clear understanding of what character aspects are desirable for the job, what associated tasks are inherent in the position, and what leadership skills are critical to successfully fulfill the obligations that a chief resident has to peers and faculty. A good chief resident can often be the difference between a smooth year for residents and staff or a year of constant miscommunication and general discontent among both parties. We will examine our findings based on our three objectives and make recommendations for future study.
From the variation reported by participants, the position characteristics for the chief resident are significantly different among residency training programs. The majority of programs surveyed selected two PGY-4 residents, many of whom had had prior leadership experience, to fill the position for a term of 9 to 12 months. However, there is no clear standard as to how programs choose their chief resident. We found this surprising as many of the prior articles on chief residents in psychiatry dealt specifically with recommendations on characteristics and selection of chief residents. The most common method reported for the selection of a chief resident was for the position to be staff chosen (34%) without resident input; however, it is interesting that the majority of programs allowed some form of resident involvement (62%). Given that the chief resident is a unique position which, as Grant et al. noted (3), acts as a liaison both to the junior residents and the senior faculty, one suggested alternative is for the position to be staff chosen with resident recommendations. This alternative allows all stakeholders to be represented. By taking resident input, staff are aware of whom the residents are willing to follow and see as a leader. Providing the staff with the final selection ensures that the chosen resident is someone who is a leader capable of the position’s demands, able to coordinate with the staff, and able to represent the residents adequately; this decreases the likelihood of a popularity contest.
Most positions permitted protected time to complete their duties, and most of the positions included a stipend. These are encouraging findings considering that on average, chief residents reported spending almost one full business day each week performing their administrative duties. This is a significant amount of time considering residency work hour restrictions. The position clearly challenges the chief resident to develop effective time management skills and also provides the opportunity to develop leadership skills. This protected time allows the chief resident to manage specific administrative tasks that expose him/her to other systems within the organization, and provides direct time for supervision to process this experience with the chief resident. Protected time might include unstructured administrative time, appointment as a member of specific organizational committees, mandated teaching opportunities, as well as directed mentorship and professional development with senior faculty. The structured nature of this model helps to define the role of chief resident by creating a formal framework within the existing organizational structure where the chief resident fulfills unique but defined duties.
Lowy and Thornton (4) previously noted that the position of chief resident in psychiatry was “often vague and ambiguous” and specifically noted that those entering the position had a “poor definition of their role.” Table 1 outlines many various duties and responsibilities reported by the chief residents. These results appear to indicate that most programs utilize the chief resident as both an administrative and leadership position. This is evidenced by the large number of respondents on such duties as being a liaison between staff and residents, making call schedules, developing residency policy initiatives, and participating in curriculum development and conflict resolution. Given that a much lower number of individuals seem to be responsible for supervising and teaching both their peers and junior residents, it appears that a number of programs do not emphasize development as a junior academic faculty member. Our findings show that approximately two-thirds of the respondents are involved in some form of supervisory or formal teaching role; our expectation was that this would have been much higher. This finding is surprising given the vital role chief residents are intended to play in academic leadership development. Incorporating chief residents into the teaching of other students and peers might prove useful. Further, it is suggested that providing chief residents with teaching opportunities enhances the appeal of residency programs to prospective applicants since nearly two-thirds of the respondents intend to seek employment in a teaching hospital.
Perceptions of the Position
Lowy and Thornton (4) previously noted that chief residents in psychiatry perceived a poor definition of their role. Our results appear to support that conclusion, as most respondents were ambivalent about the vision and expectations that they received from their program directors. However, the chief residents did strongly feel the importance of their position and its role in developing them as future leaders. Additionally, they noted that they were seen as leaders by their peers and were respected by the staff and consulted on all aspects of resident issues.
The respondents were in agreement with Lowy and Thornton’s desirable characteristics of a chief resident and noted that they viewed leadership and communication skills as the most important factors for the chief resident. These skills are extremely important as chief residents frequently solve problems within the residency and serve as a liaison between the residents and staff. However, an additional factor is the importance of managing subgroup dynamics. In this survey, 45% of programs had a pair of chief residents, and an additional 23% of programs had three or more people sharing chief resident duties. Subgroup dynamics can be beneficial in that they provide a buffer through shared stress and experiences of a leadership role and allow the chief residents to form a natural support group. However, the presence of multiple leaders can lead to conflicting visions for the direction of the program. The chief residents need to be skilled on compromise and forming a united front, even when there is internal disagreement, in order to be successful.
Knowledge of interpersonal and group dynamics coupled with skills in effective communication, time management, process improvement, faculty development, and conflict resolution represent core competencies for the effective chief resident. While psychiatry residents develop many counseling skills as part of psychotherapy training, some formal training aimed at using these principles in the workplace may prove highly beneficial. Regular mentorship and supervision similar to psychotherapy supervision may also prove useful as the chief resident processes the experience with senior executives. Faculty involved in selecting potential chief residents ought to consider reviewing a candidate’s attitudes or positions on handling peer conflicts, advocacy for emotionally charged issues for review by executives, and ethical conflicts. This may be done through a standardized questionnaire, essays, personal interview, or discussion among the selecting faculty.
Leadership Styles and Principles
A leader is an individual who is able to influence and direct others towards a common goal. There are many ways to influence others as a leader, and many theories of leadership. We chose to apply the situational model of leadership. In this model, the leaders vary between one of four styles, depending on the situation. The four styles are participating, coaching, delegating, and telling. There is no one correct style; all are appropriate depending upon the situation and the characteristics of the leader. These styles are best understood as variations on a continuum of supportive and directive behavior (Figure 1).
The residents noted that their dominant style was participatory. Chief residents may find this approach useful because, in general, they are dealing with a group of individuals who are highly competent but might require motivation. The participating style places greater emphasis on the relationships than the end task, as it is expected that the individuals are already quite aware of their end goal. It does not require that the individual set the course, but rather helps keep her or him driving towards it. This style of leadership allows followers to make decisions and be in control while the leader facilitates the discussion. This is very appropriate for a peer leadership situation as it will increase the rate of “buy in” by other residents and minimize interpersonal conflicts (8).
In this study, the respondents noted that the most important personal leadership traits included “integrity,” “dependability,” and “initiative.” Integrity was defined as a core value that allows subordinates to know that the leader is trustworthy and maintains consistency and fairness in decision-making. Dependability was defined as establishing reliability and trust in the organizational leadership. These characteristics are consistent with those noted by Mark Bender in his book Operation Excellence (9). Initiative was defined as demonstrating through courage and action a level of commitment to the growth and progress of organizational change. In Operation Excellence, Bender noted that the five traits that people look for in their leaders are courage, openness, drive to win, fairness, and trust. As clinical medicine continues to evolve at a blistering rate, so do the organizational systems managing it. The rate of change in these organizations can be enormous from residency academic requirements, residency review committee policy changes, environmental shifts, staff turnover, and managed care initiatives to rapidly changing priorities in individuals and families. The chief resident and, more importantly, the house staff expect to confront these issues regularly. Trust is enhanced when the house staff appreciate the traits of integrity, dependability, and initiative in the leadership style of the chief resident.
John Maxwell noted in his book, Developing the Leaders Around You (10), that one of the keys to developing future leaders is to nurture them and equip them with the skills necessary to achieve future success. The results in this study demonstrate that chief residents do feel that their understanding and their capabilities are being enhanced. One explanation for this may be due to the unique relationship between the chief resident and program director. The chief resident is often the program director’s top adviser on resident issues. Additionally, chief residents have greater access to faculty and residency planning, allowing them to see the inner workings of an academic program and giving them an excellent cornerstone for a career path in academic medicine. Furthermore, chief residents are given opportunities to attend conferences, such as the APA Leadership Development Conference, which allow them to enhance their current skills and develop new ones. Lastly, an equally important aspect of these opportunities is the relationships that the attendants develop with their colleagues and the mentoring opportunities that they create.
A majority of the respondents felt that they would repeat the position and noted that they would seek leadership in local organizations. In addition, nearly two-thirds noted that they would seek national leadership positions. This is an encouraging result as it indicates that the chief resident position is not only a leadership development opportunity but that it is helping to inspire future leaders in psychiatry. This indicates an area for future study. However, it is also important to look at other methods for developing our future leaders. The chief resident position develops the leadership abilities of only one or two residents per year. It is imperative that residency training programs look at various avenues of leadership development to include development as educators, clinic/ward management, and administrative policy development.
Leadership is an applied behavioral science. As our specialty comes under attack for its validity and science, it is imperative that we develop strong leaders for the future. We have identified what our junior leaders feel are their strengths and what benefits they feel they receive from their leadership opportunities. However, this self-report survey that used forced responses is limited. First, due to our selection method, our sample only represents one-third of all psychiatry residency training programs and only one chief resident from each program, when many of the programs cited that they have multiple chief residents. Additionally, our information is limited by the tool that we created. Some areas not evaluated in this survey include the quantity of training provided to residents in leadership development and the amount of feedback and teaching that they receive during this process. This represents an area for future study. We hope that this study will serve as a starting point for future initiatives and studies emphasizing and outlining methods for leader development in psychiatry. Future initiatives should consider focusing not only on the chief residents themselves, but also on others affected through their leadership, including program directors and a cohort of residents.
Many organizations outline their vision, mission, and values to provide direction for their developing members. A review of the APA Web page shows that the organization emphasizes quality, respect, support, and leadership development, but outlines little as how to accomplish that goal. Another organization, the Association for Academic Psychiatry, emphasizes career and academic development. We feel that these two organizations are national leadership groups that should examine the importance of leadership development at the residency level and consider outlining the values expected of their leaders and the plans and methods for developing them in residents.
This work was part of our employment with the federal government and is therefore in the public domain. The stated views are those of the authors and do not represent the views or the policy of the Department of Defense. No industry grants or financial support were used in this project.