The chief resident occupies a challenging position within academic departments of psychiatry. He or she is clearly a resident, but assumes faculty roles as a supervisor and teacher, and attends faculty-only meetings to represent residents. The chief resident is a hybrid creature whose roles and responsibilities are sometimes poorly defined. We surveyed training directors in general psychiatric residency programs to better understand the nature and scope of chief resident positions, the methods of selection within departments, the duration of the term, and the time available for administrative duties (1, 2). Our summary data provide a picture of the chief resident position within general psychiatric residency training programs.
A survey of the available literature in the field provides little quantitative information on the roles and responsibilities of chief residents (3–6). Past surveys of chief residents and training directors in psychiatry (7–9) have focused on satisfaction and perceived benefits from serving as chief resident. Other articles and published references on psychiatric chief residents (10–12) have discussed various aspects of the chief resident experience, including the process of deciding to be a chief resident, the administrative education inherent in the chief resident role, and the roles of chief residents as information managers and as therapists to staff. The annual chief resident training for chief residents from around the United States, reported by Neal Whitman (13) at the University of Utah, provides a broad overview of the kinds of “management skills” that have proven useful to chief residents in all specialties. From surveys of program participants, the most highly valued skills are, in descending order, giving feedback, delegating duties, building teamwork, managing time, making presentations, making rounds, coping with stress, teaching at the bedside, writing memos, and managing meetings (13). A recent article (14) notes that nearly two-thirds of respondents to a survey of the attendees at a chief resident leadership conference were selected with both resident and faculty input.
A two-page survey was sent to each general psychiatric residency training director at 182 programs using the American Association of Directors of Psychiatric Residency Training (AADPRT) mailing list from 1994 to 1995. The survey inquired about the size of the program, number of chief residents, length of chief resident terms, method of selection, written job descriptions for chief resident positions, and percentage of time devoted to administrative responsibilities. Three questions focused on the potential benefits of having a job description, with responses coded on a 5-point Likert scale. We also asked about resident organizations and retreats. Copies of written job descriptions for chief resident positions were requested from respondents to be returned with the survey. We followed-up with programs 1 month after mailing the survey to maximize the response rate.
The 2006 survey was an online version with the same wording as the earlier, paper-based survey. It was e-mailed to general psychiatric residency training directors using the AADPRT e-mailing list for 2005 and 2006. Follow-up e-mails were sent at approximately 4 and 7 weeks to maximize the response rate. Our survey was exempt from Institutional Review Board review in 1995 as educational research and was not formally reviewed again in 2006 because no unique identifying data were requested.
In 1995, surveys were returned from 96 programs for a response rate of 52.7%. We obtained written job descriptions of chief resident positions from 68 programs (70.8%) that responded to the survey. In 2006, surveys were returned from 93 programs for a response rate of 50.5%. No copies of written job descriptions were solicited in 2006. The major findings from the surveys are summarized in Table 1 and Table 2.
Our survey results provide the most current information on the general structure of the psychiatric chief resident position in residency training programs. Nearly all programs that responded to our survey have a chief resident, with a mean of two chief residents per program. Most programs select their chief residents through a combination of faculty and resident decision-making, although 30.6% of 96 programs in 1995 and 29.2% of 93 programs in 2006 restricted the selection process to faculty, confirming that a majority of responding programs follow recommendations for selection (1, 2) and that the program data match the chief residents’ responses in the 2004 survey (14). Chief residents who are selected, at least in part, by the faculty are thereby empowered by this important constituency group. A joint selection process, which includes both faculty and residents, allows chief residents to work effectively with both groups. Chief residents who are selected only by residents may be seen as merely resident advocates and not as partial representatives of the faculty to the residents.
The most common chief resident year was postgraduate year (PGY) 4. Only 7.3% of programs in 1995 and 6.7% of programs in 2006 supported a PGY-5 chief resident position. The PGY-5 chief resident has several advantages, such as greater separation from his or her peers to function more effectively as an authority figure. In our experience, the most significant challenge for most PGY-4 chief residents comes in working with fellow senior residents in the program, because they have more status and power than their colleagues and view the chief resident as a peer. The PGY-5 chief resident also has more time to devote to administrative duties, having completed his or her educational requirements for training. Finally, the PGY-5 chief resident has the benefit of an “immersion experience” to focus on the chief resident role and identity. The disadvantages of a PGY-5 chief resident position are primarily the additional time and cost to the chief resident of devoting an additional year to residency training. This significant sacrifice may restrict the potential recruitment of strong candidates to the position. The PGY-5 chief resident may also be seen as too distant by the residents to function effectively as a resident advocate and support.
An interesting finding in the 2006 survey was the large increase in programs offering a PGY-3 chief resident position, from 2.4% of 96 programs in 1995 to 16.6% of 93 programs in 2006. We are unsure how to interpret this change and speculate that it may be more common in smaller programs, where there are few PGY-4 residents due to early entry into child psychiatry. A follow-up survey that identifies smaller programs and explores this hypothesis is needed.
Most programs provide a 12-month chief resident term, which provides the chief resident with sufficient time to learn the job and the continuity necessary to build credibility (1). Only 19.4% of 96 programs in 1995 and 12.9% of 93 programs in 2006 had shorter terms.
Chief residents usually assume many of their duties in the last quarter of their PGY-3 year, after the selection process is completed. They are then busy in the early part of the academic year with orientation activities, making the call schedule, troubleshooting, and transitions. Midyear brings recruitment activities and an opportunity to consolidate identity and roles. It is only in the last half of the year that chief residents have typically developed real confidence and efficiencies in their work. Shorter terms would significantly constrain the learning opportunities and interfere with this developmental process, although some might suggest that a shorter term would prevent burnout.
The majority of responding programs had resident organizational or governance groups and conducted regular retreats, with a significant increase from 56.5% of 96 programs in 1995 to 75.1% of 93 programs in 2006, suggesting that departments are paying more attention to the group dynamics inherent in resident cohorts. Resident organizational groups provide a significant challenge to chief residents. The advocacy role of the organizational or governance group often puts the chief resident in a faculty or authoritative role with the residents. Resident organizational groups provide chief residents with an excellent forum for communication with the resident group as a whole (15). Resident retreats provide a similar opportunity and challenge for chief residents, and the organization and leadership of retreats is frequently in the chief resident job description. Chief residents can use the retreat as an opportunity for program or curriculum review, resident support, and experiential learning in group dynamics and group process.
A majority of responding programs in 1995 and 2006 reported having a written job description for the chief resident. Of the 68 written job descriptions provided by programs in the 1996 survey, the most commonly included elements were a delineation of specific tasks, duties, and objectives; a description of the selection criteria and process; a description of the process of supervision; and a statement of the unique status of chief residents on the boundary between faculty and residents.
Our survey results on the benefits of written job descriptions for chief residents support our belief that a written job description is helpful. The ambiguous position of the chief resident, who can function as both “faculty” and resident, makes the specificity inherent in a written job description a useful anchor to senior residents attempting to define their roles and responsibilities in a new position. Some variability in the role is desirable, and the job descriptions should have a clear statement on the flexible nature of the role, while including the common elements noted above (13). Ultimately, the exact role of a chief resident may be a function of the group dynamics in a given year in a training program, the chief resident’s professional developmental stage, and the leadership style of the training director or department chair.
Our instrument and methodology have some limitations. Our sample represents only a little more than half of the programs, leaving some possibility that our results are not representative of the actual practices seen in all of the residency programs. Also, the survey is a self-report instrument and not an independent measure with potentially more objective data. However, our results are consistent with the answers to similar questions posed to chief residents of psychiatric residency programs in 2004 (14).
Our survey results provide important information on the general structure of chief resident positions in psychiatric residency training programs. Joint faculty and resident selection, 12-month terms, protected time for administrative duties, and written job descriptions are all helpful features common to most programs, and the data support that most programs use some or all of these features. We believe that most programs would benefit from considering these aspects when designing their chief resident programs. These structural supports, regular administrative supervision, readings, and specially designed training experiences for psychiatry chief residents, such as the annual Tarrytown Leadership Conference (16), are important components to a successful chief resident experience. In addition, there is an annual chief resident training held at the Institute for Psychiatric Services (17). The chief resident position in psychiatry can provide a motivated resident with important leadership experience if he or she is properly prepared, is selected by faculty and residents, has a 12-month term, is included in important decision-making, and has a specific job description.
Manuscripts authored by an editor of Academic Psychiatry or a member of its editorial or advisory board undergo the same editorial review process, including blinded peer review, applied to all manuscripts. Additionally, the editor is recused from any editorial decision making.
At the time of submission, Drs. Schwartz, Servis, Cox, Lai, and Hales disclosed no competing interests. Dr. Lim is a member of the Speaker's Bureau for AstraZeneca and has received educational grants from AstraZeneca and Pfizer.