18. Challenges for large residency programs

Introduction

Becoming a program director (PD) is often intimidating: there’s so much to learn, and so many people depend on you. This is true for all PDs, whether you’re the PD of a big program or a small program. As you read this chapter, you will probably sense very quickly that most of the challenges that are discussed are not unique to large residency programs. In fact, most are probably common to all programs, regardless of their size, and this is true of much of the advice in this chapter too.

What is unique about large programs is just how quickly things can deteriorate if challenges are not addressed. For this reason, this chapter is as much about understanding what the challenges are as it is about finding solutions to them. Although it would be wonderful to have solid evidence to inform us about these challenges, this unfortunately has not been an area of great research to date.

Although there are a number of topics addressed in this chapter, they all ultimately relate back to the principles of policy and process. If you are the PD of a large program, it is imperative to have a consistent way of doing things and to ensure that everyone involved with your program is aware of these approaches. By putting policies and procedures in place, you will provide a clear roadmap for all involved and ensure that everyone understands what is expected of them, what their responsibilities are, and how they are to achieve their objectives.

The following are a couple of examples comparing similar situations in a smaller and larger program:

Example 1

Small program: Dr. Jones is a fourth-year resident in endocrinology. He is on the consult service with Dr. Smith. He asks Dr. Smith for two days off to attend his brother’s wedding. Dr. Smith agrees but does not realize anyone else needs to be informed. Dr. Smith later sees you in the office and happens to tell you about Dr. Jones’ request. While you are OK with this absence, you make sure the documentation is in place to record the absence.

Large program: Dr. Jones is a fourth-year resident in pediatrics. He is on the clinical teaching unit with Dr. Smith at the community teaching hospital. He asks Dr. Smith for two days off to attend his brother’s wedding. As you work at another hospital, you don’t see Dr. Smith regularly and therefore do not learn about Dr. Jones’ absence. The absence is not properly recorded. Dr. Jones takes an additional two days later in the year. The other residents in the program hear about these extra days off and are not happy. They start to take similar liberties with their days off, and you are not aware that this is happening.

Example 2

Small program: Dr. Toms is a senior cardiologist and attends on the ward. There is growing concern among the residents, four in total, that Dr. Toms is not teaching the residents sufficiently and is often absent from the ward for long periods of time. When you see the residents at their academic half-day, the residents share this with you, and you follow up immediately on their concern.

Large program: Dr. Toms is a senior cardiologist and attends on the ward. There is growing concern among the residents, 50 in total, that Dr. Toms is not teaching the residents sufficiently and is often absent from the ward for long periods of time. When you see the residents at their academic half-day, they don’t feel comfortable sharing this with you in such a large group, so they keep silent. You eventually review the aggregate of Dr. Tom’s annual teaching reports at the end of a two-year cycle and become aware that there is a significant issue.

So, what went wrong in these examples? In fact, what happened in the small programs was no better than what happened in the large program, but there are inherently more opportunities to prevent misses in small problems simply because of their size. In a large program, it is much more important to have infrastructure in place for these sorts of situations and more.

Setting your large program up for success

As the PD of a large program, I’ve come to realize that there are five key ingredients that help set a program up for success: good communication, trusting relationships, clear policies and procedures, compassion and innovation. Generally speaking, if you attend to these five areas in your large program, you and your program will thrive.

1.  Communication, in all its facets, is paramount to your success as the PD of a large program. It is not enough to just hope you will see your residents, your teaching staff and your administrative support staff on a regular basis to share your ideas, plans and concerns and hear theirs. These interactions should be deliberate and planned on your part, whether or not those around you recognize this or not. It is very easy to get caught working in your office to complete the myriad of administrative tasks for which you are responsible as the PD, but it is important to make time for everyone involved in the program. Most PDs will want to schedule regular individual meetings with their residents not only to review how they are progressing but also to have valuable dialogues with each resident about their progress and their insights and to discuss how they can best succeed moving forward. You may want to also schedule times to meet with the residents as a large group, or with particular training cohorts, to discuss broad topics and concerns and to answer the residents’ questions. Similarly, you may want to schedule times to meet with groups of teaching staff, especially those you may not see regularly in your day-to-day schedule because they work in a different area of the hospital, in a different hospital or in a different town or city. Scheduling these communication opportunities gives you the chance to share what you are thinking about the program — its current successes and challenges — and ensure that your views match what the residents and teaching staff are thinking. Such discussions may inspire you to introduce innovations into your program. They will certainly demonstrate to all of your stakeholders that you are a strong leader, that they are important to you and that you are listening to them.

2. This leads to trust. Communication is an important step to developing trust. Trusting the educational leaders around you is critical to your success and the program’s success. As the PD of a large program, it will be nearly impossible for you to do it all. You must be comfortable relying on a team of other physicians and administrators who can take the lead on a variety of activities. At different institutions, that team may be called different things. You may want to consider appointing one or more associate PDs to take the lead in specific areas of your program. Perhaps your residency program committee has strong members who can take on activities. With Competence by Design, having a strong and empowered competence committee chair can make a big difference for you and your program.¹ If your program has multiple sites, assigning site leads can be very helpful. For the people in any of these leadership positions to be successful, you need to let them “do their thing”; don’t micromanage too much. By giving independence to other members of your team and showing that you trust them, you will instill a culture where both physician and support staff feel engaged and want to contribute their best to your program. As long as the communication channels remain open, you will be aware of the work they are doing and will be able to help shape that work in a way that brings everyone comfort and success. The same principle applies to your residents. Many residents feel a sense of pride and ownership in their residency program and want to bring change. By entrusting your residents with appropriate projects, you will enable them to become another integral part of the team that ensures the work gets done. In particular, it is critical to assign administrative tasks to your chief residents to further develop that level of engagement. However, do not limit leadership opportunities only to your chiefs; there are many residents who have strengths and talents that can be used in a variety of ways in your program.

3. Communication and trust go a long way to ensuring that your program has the right policies and procedures in place and that as many stakeholders as possible are aware of them. Not much thought tends to be given to policies and procedures when things are going well. They become much more important when there is a problem, particularly when it involves a resident or staff member. Following policies and procedures is critical in large programs in these types of situations, as it helps to ensure that everyone is treated fairly, both in the present situation and when similar situations arise in the future.

It is important to think about how you will communicate your program’s policies and procedures. Although you will have opportunities to directly share them with your program’s stakeholders, they may forget them when things are going well. It can be very helpful for large programs to have a passive, easy-to-access communication channel for policies and procedures, and indeed all program messaging. If you don’t have one already, definitely consider developing a website that can host your information and share it with the world. If your program already has a web presence, make sure to allocate appropriate resources to your site to ensure that the content is always up to date; you don’t want residents, staff or program applicants to see a website that is a few years out of date. Good examples include AIMRS.ca (University of Alberta Internal Medicine ResidentS), University of Toronto Emergency Medicine Resident Resources (http://www.deptmedicine.utoronto.ca/emergency-medicine-resident-resources) and the McGill University Internal Medicine Residency Program’s website (https://www.mcgill.ca/internalmedres/). Consider “pushing” certain policies and procedures to the relevant stakeholders regularly, especially when there is high turnover, for example at the beginning of the academic year.

4. Understanding and compassion. When it comes to program procedures, two additional points of advice are important. First (and perhaps it goes without saying), make sure you hear all sides of any “situation.” If a resident issue arises, it is not uncommon for you to hear about it from a staff person first, and what is shared is usually concerning. If you neglect to take the time to hear the resident’s side of the story, you might consider serious consequences for the resident that may not be warranted or appropriate. With a large program, you may not directly interact with the resident in question as often as you would if your program was small, so taking the opportunity to hear from your residents not only ensures fairness but also enables you to get to know them better. This leads to the second point. As important as policies are, equally important is compassion. In smaller programs, it is not unusual for residents to seek out their PD for advice not only about training but also about their personal life and how it may be affecting their work. Residents in larger programs need their PD’s support as much as their counterparts in smaller programs as they deal with the challenges of life and the start of their career. This doesn’t mean you should let residents progress if they are not meeting their competencies, but it does mean you need to make decisions that take into account the unique context of the resident, their life circumstances and the relevant policy. You should work to understand a resident’s concerns or challenges through their identity and experiences and hear their perspectives on an issue. If you don’t know the resident well when a concern is brought up, make sure you take the time to learn about them, as it can lead to insight into why they were brought to your attention in the first place. This is one of the most difficult parts of being a PD, and it is perhaps more challenging for PDs of larger programs where it may not be possible to have the same relationship with every resident. However, it can also be very rewarding.

5. Innovation. In a large program, there are so many moving parts and so many people involved at various levels that it can seem daunting to even contemplate changing gears or introducing change, especially if the program is doing well. However, don’t let that intimidate you. Many PDs are also innovators and have many good ideas. Remember that over time, most programs that stop innovating will stop running well, so don’t be shy about introducing your ideas and trying new things. Although it may not be the best idea to make changes in your first few days on the job, it is not only appropriate but expected that you will consider change in a thoughtful and respectful way as you learn about the program. Building strong relationships with your stakeholders will pave the way for successful change.

Taking over a large program is often a major career change for PDs. You may have been involved in the program in another capacity before, or perhaps you were the PD of a smaller program. Being the PD of a large residency program will take up a lot of your day and will probably take you away from some of the responsibilities you previously held. For many, those other responsibilities may have included dedicated time for scholarly work. You should remember that being a good PD will require the skills you used in that work. For example, data collection is critical not only to track the progress of individual residents, teaching staff and administrative staff but also to tell you how your program is doing overall. It helps inform change and provides you with a better way to communicate your program’s successes, challenges and change to your stakeholders. Being a PD of a large program is a wonderful opportunity for scholarly work, as you have many more data points at your disposal than the PDs of small programs. If used well, those data points can not only inform your program’s progress but also can be shared with others across the country and around the world so that they can learn from what you are doing.

As an example to put everything together, let’s examine the annual process that is the Canadian Residency Match. In a large program, you can’t do it all yourself. You need to establish and follow fair, easy-to-share rules and procedures around your metrics for file review and interviews.² You will need a large team of staff or residents or both to interview the many candidates who will apply to your program and you need to be able to communicate to your team what qualities you are looking for in applicants. You need to trust your team to do that work well and to represent your program effectively to the applicants. You also need to communicate about your program to applicants directly; this will probably be done electronically, in advance of the interview process. When you are done, you will have ample amounts of data that you can employ to innovate, update and improve your process for the following year, as well as to report on your experiences to other programs and PDs.

Conclusion

In the end, make the job of being a PD your own. With strong communication and relationships, you can build trust with those around you. Communication and trust will enable you to build program infrastructure that creates a learning environment that is fair. Even though your program is large, creating a balance between the rules and compassion remains key to your work. And don’t forget to be a scholar, as it will make your work that much stronger and your experience as PD — which is satisfying regardless — that much more meaningful and rewarding.

References

1. Managing competence committees. Ottawa: Royal College of Physicians and Surgeons of Canada. Available from: royalcollege.ca/rcsite/cbd/assessment/committees/managing-competence-committees-e
2. Bandiera G, Abrahams C, Cipolla A, Dosani N, Edwards S, Fish J, et al. Best practices in applications and selection: final report. Toronto: Postgraduate Medical Education, University of Toronto; 2013.