Despite the chief resident’s importance in psychiatry residency training, little has been written about how chief residents make meaningful contributions to training. It is clear that many struggle to do so (1, 2). Some fall into a “double agent” position: trusted but resented by both residents and faculty (3). Others attempt to implement sweeping improvements to the residency only to realize their ambition has outstripped their power (1). Frustration builds in the resident leader whose experience discourages talented younger residents from even seeking the chief residency (4). Chief residents who struggle in these and other ways serve in positions plagued by ambiguity. Nearly every article on the subject cites the detrimental effects of a vague or absent job description, a hazy definition of power, or an ambiguous role within the department (1–7). Residency programs that fail to provide clear expectations and delineated authority for their chief resident impair their resident leader’s ability to act decisively and lead successfully. We propose a structure based on the most effective leadership roles used by chief residents to enhance the resident leader’s ability to solve significant training problems and improve the residency program.
Though chief residents function in numerous roles, those of the legislative leader and representative leader are consistently cited as uniquely important (1–5, 8).
An effective chief resident leads peers as a “first among equals” by guiding residents to resolve problems through inclusive processes (1, 2, 4, 8). Experts in the field of leadership label the technique of leading others without the advantage of concentrated executive power “legislative leadership” (9). Using this method, a chief resident, even with very limited unilateral decision-making authority, can solve significant problems and make important contributions to training.
When an intern dropped out of the residency, the psychiatry chief resident at a large, east-coast metropolitan training program of more than 50 residents was presented with the challenge of uncovered call nights. Heated discussions among residents were resolved when the chief resident discussed the problem with them at their weekly meeting, solicited and refined their proposed solutions, and had them vote on the solution.
The chief resident operating as a legislative leader encourages his or her peers to confront facts, facilitates their active participation, cements a consensus, and ensures that action is taken. Issues best handled through legislative methods include setting and adjusting call schedules, resolving interpersonal disputes between residents and improving morale and cohesion by planning and executing social events, such as year-end banquets and retreats. A formalized forum, such as a resident council, promotes resident discussion of these types of training problems and provides a setting for the chief resident to engage his or her peers in the problem-solving process. If the chief resident, as the head of the council, sets an open and vibrant tone, the venue reduces passive, unproductive complaining and instead cultivates each resident’s active participation, empowering the chief resident to focus his or her energy toward productive goals.
Though vitally important, the chief’s legislative leadership does not represent a complete picture of an effective chief resident. Chief residents, no matter how empowered by their peers, cannot solve every problem or make lasting changes within the program without enlisting the expertise and administrative power of the teaching faculty. To do so, the resident must call upon the second essential role of the chief: the resident representative leader to the faculty.
The Representative Leader
An outpatient psychiatric clinic hired several mental health providers. The chief of the clinic appropriated office space from the residents for the new clinicians’ use. The four residents and two medical students, now sharing two offices, struggled to divide the space between them. The attending physician listened but took no action, citing a general lack of space in the clinic. The chief resident appealed to the attending but was not successful. With no resolution in sight, the chief resident presented the issue to the residency program director who insisted that unless the clinic faculty created more resident workspace, residents would cease to rotate on the service. Within 2 weeks, the attending psychiatrist had a large storage area improved and made available for residents to perform clinical evaluations.
Only teaching faculty have the authority to resolve many important training issues such as setting the optimal number of residents for each rotation, altering the length of a rotation, or improving residents’ working conditions. As the resident representative leader, the chief resident collects and clarifies resident perceptions to provide efficient and relevant feedback to the faculty. This representative role involves much more than simply liaising between faculty and resident groups. The chief resident attempts to shape the faculty’s decisions by advocating for specific actions to resolve significant issues facing residents (2, 3, 5, 8).
The chief resident serves as a representative to all teaching faculty, but most importantly, to the residency program director. In the above example, the chief residents’ representation of the residents’ concerns about work space did not produce positive change until the program director reinforced their position. The program director’s clear understanding and decisive action resulted, at least in part, from a series of discussions with the chief resident. Regular conversations form the basis of a distinctive working relationship through which each leader comes to appreciate the unique experiences and goals of the other. The chief resident learns to anticipate the program director’s objections to resident initiatives and modifies them prior to making proposals. The program director, in turn, increasingly appreciates the chief resident’s biases and weighs his positions accordingly. Each plays to the other’s strengths and offsets weaknesses. The working relationship fosters a process of exchanging information, working out disagreements, and cementing a plan of action that, as illustrated in the above vignette, creates a powerful common agenda between the leader of the residents and the leader of the residency program.
Successful operation in the two principal leadership roles requires the chief resident to possess credibility with residents and faculty, broad perspectives on problems, and durable working alliances. The residency program provides its chief resident with these features by structuring the chief resident position around three parts. First, faculty and residents must select the chief resident through a joint process. Second, the chief resident must serve for the duration of the academic year. Third, teaching faculty must include the chief resident in any significant decision affecting residents. The residency program must provide these features of credibility, stability, and inclusion to empower the chief resident to lead in both legislative and representative roles.
Residents generally become eligible for selection as chief resident at the end of their third year. By that time, faculty and other residents have observed how they treat patients, interact with peers, handle sensitive information, and encounter adversity, and, on that basis, have decided whom they would trust with the job of chief resident. The chief resident’s credibility, therefore, begins with a method of selection that includes both residents and faculty (10, 11). One residency program begins its chief resident election process each spring with resident nominations of any rising senior resident. The program director reviews the list of nominees and, after discussion with other faculty and the chief resident then in office, removes residents deemed to be poor candidates from consideration. All residents vote on the faculty-approved list in a confidential ballot.
The resident nomination/faculty review/resident vote process ensures the installation of a chief who has earned the trust of both faculty and residents. The transparent and inclusive election process endows the chief resident with a foundation of credibility.
Since the beginning of the academic year, a junior resident had struggled with his clinical responsibilities. Anticipating a problem in the second half of the academic year when the resident was scheduled on a demanding inpatient service, the chief resident sought out the ward’s teaching faculty. Together, they created a plan to support, instruct, and monitor the resident.
If the faculty/resident consensus produced by the joint election process forms a basis of credibility for the chief resident, then a year-long term adds to it continuity. Complex problems take time to understand and even longer to solve. If a chief resident hopes to make meaningful contributions, the resident leader has to take on complicated problems without easy answers. How can resident morale be improved? How can we enhance the quality of medical student applicants or assist a struggling resident? Making headway on these issues demands vision, multifaceted plans, long-term working relationships, and trial and error. If a residency program rotates its chief resident position among several senior residents within an academic year, it robs each of the opportunity to solve significant problems.
To grasp and solve residency problems, the teaching faculty must include the chief resident in deliberations of every major resident issue. Inclusion reinforces to all residents that their chief is a viable member of the residency leadership team. Confident that the chief resident has a “seat at the table,” residents view their elected leader as the person most able to help them when significant problems arise. As residents in each year group and on rotations in every area of the department seek out the same chief resident to voice concerns or make suggestions, the chief gains a uniquely comprehensive understanding of the problems facing the residency. When faculty consider a problem, the chief resident can impart, with considerable authority, his or her wide-ranging grasp of the issue. If teaching faculty exclude the chief resident from the decision-making process, other residents quickly sense the divide between resident perception and faculty action. Inclusion enables the chief resident to explain the faculty’s rationale behind important decisions and reassures residents that their opinions were considered during deliberations. In short, faculty inclusion establishes the chief resident as an effective vehicle for enacting change and as the advocate and leader of each resident.
The chief resident’s introduction to administration and management has been cited as an especially desirable feature of the position (1, 4, 12). Surprisingly though, serving a term as chief resident does not appear to influence psychiatrists towards a career in administration (13). This may be a consequence of their frustration with poorly structured and ill-defined chief resident positions. A positive experience, in contrast, defined by clear roles may entice former chief residents into careers in academia or administration, areas clearly in need of more applicants (4, 14–16).
All psychiatrists, even those outside administration or academia, serve as leaders. Chief residents who have served in training programs with unambiguous, clearly structured positions successfully learn leadership techniques. These residents emerge more prepared to lead clinical and research teams than former chief residents whose leadership development was restrained by ill-defined chief resident positions.
We propose two broad leadership roles and three structural features through which residencies establish their chief residents as effective leaders. Credibility through election, continuity in the year-long term, and inclusion by the faculty enable the chief resident to unambiguously assume the crucial roles of the legislative leader and representative leader. In doing so, psychiatry residencies significantly reduce the ambiguity and uncertainty which commonly hamper chief residents in their efforts to solve problems and achieve meaningful change.
The views stated in this paper are those of the authors and do not reflect the policy or position of the Department of the Army, Department of Defense, or the U.S. Government.