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Author: Olivier Jamoulle, MD, FRCP

Co-Author: Agnès Räkel, MD, FRCPC


Objectives

After reading this chapter, you will be able to:

  • describe the unique opportunities offered by small residency programs
  • outline common challenges faced by small residency programs
  • find ways to address these challenges to ensure the success of your program

Introduction

Being a program director is a wonderful adventure regardless of the size of the program. Interestingly, the tasks of program directors, residency program committee (RPC) members and competence committee members are largely the same for all sizes of programs. While it is true that running a residency program — small or large —  is fulfilling, this leadership position must be nurtured and the presence of a support network is invaluable.

In the literature, a small residency program is defined as having fewer than six residents per cohort (residency year) (1), a medium-sized program has seven to 12 residents per cohort and a large program has 13 or more residents per cohort. This chapter highlights the advantages of small programs and discusses the most common challenges they face and how to mitigate them.

Advantages of small programs

There are many advantages to running a small residency program. You will appreciate these as you settle into your new role, and they will make your experience even more rewarding.

In small programs, residents can have regular contact with you and with your program’s RPC members, which makes it easier to quickly create connections and a sense of belonging than in large programs. Having a small number of residents to manage will make it easier for you to schedule periodic one-on-one meetings with residents and provide more regular, personalized mentoring. By meeting with each resident regularly, you will be able to adjust their learning plan on the basis of their needs and their career goals. For example, you may find it easier to intervene and organize rotations with tailored learning opportunities when a learner needs remedial support or instruction. In addition, it may be easier to track resident wellness and other concerns when the group is small.

In small programs, there is often great solidarity within and between cohorts, beyond the natural support among peers that is evident in all programs. Residents in small programs are inclined to want to give to the next group of residents what they themselves received when they arrived. Given how closely residents and teachers work together in small programs, there may be an increased sense of shared identity around their common goals. However, it should also be noted that smaller programs can come with challenges for minoritized or underrepresented residents, who may feel isolated and alone.

The views of some residents are less likely to go unnoticed in small programs than in large programs. The flip side of this benefit is that some residents in small programs may not be as forthright in the anonymous feedback they provide because of fears of being identified.

The strength of a program often lies in the level of interest and participation of its residents and the level of commitment of its teachers, including their motivation and desire to see their learners thrive. When the program director knows each supervisor personally and is familiar with their individual expertise, it is possible to adjust the training program to ensure that the residents’ progressive acquisition of competencies and rotations is in line with their career goals. Residents’ proximity to their supervisors facilitates the formation of longitudinal relationships and continuity in assessment and feedback; these in turn support coaching over time, in line with a competency-based approach.

Small programs can offer numerous and diversified clinical exposure and learning opportunities that are more than adequate to allow residents to acquire the expertise they will need in practice. As residents are often called upon first to assess patients, there may be less competition among them for access to clinical exposure.

Small programs also offer advantages from a logistical perspective. While the composition of committees and operational structure of a small program is identical to that of larger programs, smaller programs can often be more flexible and nimble because there are fewer stakeholders and they know each other well. When there are fewer people involved, communication and consultation can happen more efficiently and changes (such as curriculum changes) can be implemented more rapidly. In addition, it may be easier to mobilize your colleagues to participate in a committee, a project or an innovation when you know them well or when you see them regularly. Any adjustments that need to be made to the program can be made on a day-to-day basis and often more easily than in larger programs.

Common challenges and possible solutions

Confidentiality and anonymity

Smaller programs may find it more challenging to ensure confidentiality than larger programs, mainly because the RPC and competence committee members, teachers and residents know each other well. You will need to regularly remind everyone about the importance of maintaining confidentiality in your program and ensure there are clear mechanisms for doing so, such as having RPC members and residents sign annual confidentiality agreements and using a secure platform (hospital- or faculty-based) for confidential information or assessments (rather than email).

Regular program evaluation with input from residents is essential to support continuous quality improvement. As program director, one of your tasks is to support and nurture a culture that encourages feedback. It is important to note that it will be harder for your residents to remain anonymous when they provide feedback because they know each other and the faculty quite well. A solution to this situation might be to ask them to provide a single assessment for the group or a collective assessment written by consensus in the first person plural (“we”). This approach can also be used to assess individual rotations and teachers.

Conflicts of interest

Although close relationships among residents and teachers in a small program can be a huge asset, they can increase the risk of conflict of interest. Since smaller programs have fewer teachers, each teacher often plays multiple roles in the program. They can be supervisors, mentors, coaches and evaluators all at once, and they have to manage these different roles without allowing one to influence another.

The individual who assesses a resident’s work during a rotation must be objective. In smaller programs, there may be a certain degree of complacency (because the assessor knows the resident very well), an inability to step back (because the assessor is always with them) and even a tendency to submit assessments late (because the assessor knows they will see the resident again very soon, for example during the next rotation). You as the program director may have to assess several of your residents during clinical encounters. This has the potential to create tension and affect the relationship of trust that you have established with them in your role as program director.

There are strategies to limit the risk of conflict of interest. You might consider appointing a university mentor who will not be involved in the resident assessment process. You could also create a peer support group of teachers from other programs who are not involved in the assessment process as well as a wellness committee to implement innovative support initiatives as needed.

Isolation and workload for residents

When there is only one resident in a residency program, there is a risk that the resident will feel isolated. There are fewer benchmarks and it is challenging for them to benefit from sharing tips and tricks with other residents. Recently graduated residents can provide valuable support and are often delighted to do so. They can act as mentors for learning and career planning by sharing their experiences. Feel free to use them, as they will feel valued. In some circumstances, residents’ feelings of isolation in a small program can be even more challenging if they are internationally trained or minoritized individuals who feel that their personal and professional experiences are distinct from those of others.

Residents may also feel they are responsible for providing all the services when they are the only senior resident. Fearing that they will disappoint or not be recruited to a faculty position once they have graduated, they may place too many demands on themselves in terms of their clinical workload, at the expense of protected time for learning. As program director, you need to make sure that teachers understand that residents’ clinical responsibilities need to be balanced with their academic obligations and other components of their schedules. You can advocate for your residents and manage expectations on both sides.

You will also need to consider the hidden curriculum, which is everything that contributes to the resident’s training and the development of their professional identity that is not explicitly mentioned in the formal program of studies and teaching. The hidden curriculum can influence the resident positively (e.g., having a role model who successfully reconciles their clinical work and family responsibilities) or negatively (e.g., having a clinician teacher who is regularly several hours behind schedule in their clinic and finishes very late) and can affect the quantity and quality of residents’ work, their wellness, their attitude and their work environment.

It is important to consider all the potential consequences (positive or negative) of the hidden curriculum that you may need to proactively manage. Residents in small programs need to be particularly aware of the hidden curriculum, because the fact that they may feel unable to talk confidentially about sensitive situations with others could make them more vulnerable to certain pressures. Program directors can address issues pertaining to the hidden curriculum by fostering a sense of choice and agency for residents, encouraging role models to show vulnerability and seeking to co-design solutions and interventions with residents and other stakeholders.1

The multiple roles of teachers

Given that small programs have fewer residents and, in many cases, fewer teachers, than large programs, each teacher may play multiple roles in supporting program activities. As the PD of a small program, you will need to monitor and be sensitive to your team’s workload. Deliberate and regular communication with your colleagues about program activities can help keep them feeling involved and engaged. Divisional or departmental meetings can be an ideal opportunity to take stock of the RPC’s activities and solicit your colleagues’ input and support.

Teacher motivation

A small program may sometimes not have any residents at all. This poses a number of risks, such as a loss of motivation on the part of the PD and the RPC to update the program and engage in continuous quality improvement. There may also be a lack of interest in formal or clinical teaching. It can be difficult to reactivate a program after a long period without residents. One of the solutions could be to keep the program active by actively recruiting foreign trainees. This involves working with the university and departmental leadership to develop local administrative procedures and thinking through potential funding sources. The ultimate advantages would also include creating international collaborations and diversity within the program.

Resident selection

Competition for the limited number of resident places in small programs can sometimes be intense, which can create tension among applicants and stress for the selection committee, which may have to make difficult choices. The selection criteria should be reviewed regularly to ensure that they support the recruitment of future specialists who will ensure diversity within the program and meet the needs of the population. Transparency in the selection process is essential, as is avoiding any conflict of interest. Policies and procedures should be put in place to mitigate any conflict of interest or perceived bias, such as not allowing admissions committee members to write letters of support for trainees applying to their own program.

Helping your residents with career planning is an important responsibility, and you should initiate it as soon as they begin their residency. This can help mitigate a potential source of competition arising from a perceived lack of faculty positions within the specialty. These early interventions can ensure that residents in the program work in a positive learning environment that enables all of them to thrive.

Professional boundaries

The line between the roles of program directors as confidants, friends and mentors is very fine. It is important to set appropriate expectations at the outset and to maintain the necessary boundaries, while remaining available and present for residents. Everyone must be aware of their responsibilities within the program. For example, a particular mentor may be responsible for tracking a resident’s progress, and another member of the RPC or other faculty may be designated to provide career counselling.

As program director, you must avoid any conflict of interest. While you can and must provide support to residents, you also play a key role in determining whether they have acquired the competencies required to practise their discipline as medical specialists. Other program directors in your specialty, program directors of other small programs in their organization, national networks and your postgraduate medical leadership can serve as resources in this regard.

Creative solutions for resource allocation

For most training programs, regardless of location, resource allocation is an ongoing challenge. The reasons for these challenges are context specific, and thus the solutions must also be context specific.

Administrative resources

In an environment where resources are limited, small programs are often required to share. For example, you may need to share administrative support with one or more other program directors. It will be important for you to negotiate the time that will be devoted to your program, to ensure that your program’s unique tasks are adequately covered. A benefit of sharing administrative resources is that there may be synergy and efficiency in having the same individual(s) handle tasks that are very similar across programs. If the time allocated is sufficient to meet everyone’s needs, sharing administrative support can be beneficial because common tools or solutions can be shared to manage sometimes-complex processes.

Financial support for residents

As program director, you will probably want to provide support to the residents in your program for academic activities (e.g., travel to international conferences) and wellness activities (e.g., team building activities). However, it may be challenging to obtain funding if you are unable to meet the minimum number of residents for a particular activity, and the cost per person may be higher. You may want to consider cost sharing with other programs. Obtaining unrestricted educational grants, seeking voluntary contributions from the members of a service or pooling the financial resources you have obtained with those obtained by other small programs will make it easier to support the initiatives you want to put in place.

During curriculum planning, for example, it is often difficult to request a teacher’s services when the number of students is low. You should not hesitate to group courses in a specialty and combine them, where applicable. You can also arrange for residents to take courses offered in related programs (e.g., courses on a pathology common to two specialties, biostatistics courses, research methodology courses). If you do not have the resources on site, you can also offer residents registration for courses offered by international experts (e.g., MGH, Harvard). Consider involving residents in course committees as they can help to identify creative and innovative solutions and improve course quality.

Conclusion

The admission of a resident to a small program offers them the possibility of developing a professional identity at a very early stage through close proximity to their teachers and other role models, a sense of belonging because they have the opportunity to contribute to many committees, and peer support because they get to know their colleagues well. They will receive exposure to a wide variety of clinical situations and opportunities for autonomy and independent decision-making.

As program director, you have a unique opportunity to encourage a sense of solidarity both among residents themselves and between residents and teachers, and to foster the sense that your program is a close-knit team. Because you know all the clinicians in your program, you can get hold of them, motivate them and involve them in actively improving the program more easily than if your program was larger. Your program’s small size also means that you will be able to be more agile in managing it.

Running a small residency program can present some challenges. Issues such as maintaining boundaries, ensuring confidentiality, developing resources, raising awareness of the hidden curriculum and raising financial support require particular attention and thoughtful, creative solutions. Take a visionary approach based on best educational practices, and you will find this leadership role in medical specialist training to be extremely stimulating.

References

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  3. Wong D, Ganesan V, Kuprasertkul I, Khouri RK, Jr., Lemack GE. Reversing the decline in urology residency applications: an analysis of medical school factors critical to maintaining student interest. Urology. 2020;136:51–7.
  4. Dahn H, McGibbon A, Bowes D. Burnout and resiliency in Canadian oncology residents: a nationwide resident and program director survey. Pract Radiat Oncol. 2019;9(1):e118–e25.
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