Two Perspectives on the Educational and Administrative Roles of the Pediatric Chief Resident

Historically, chief residents have played an important role in US graduate medical education. In the 1970s the chief resident was considered “a revered, if not feared, person who had considerable authority over matters of concern to the house staff and one whose medical acumen was not infrequently judged to be second only to that of the departmental chairman.”1 In addition, the chief role has served as an opportunity for developing leadership skills, and former chiefs are more likely to become professional leaders than colleagues who did not serve in this role.2 Although this observation could be influenced by selection bias, even born leaders can benefit from refining and applying those skills.

The chief resident position was first described in the late 1800s by William Stewart Halsted, MD, surgeon-in-chief at Johns Hopkins Hospital as a “senior resident who, having demonstrated competence in his craft was allowed to manage and operate on patients under minimal supervision.”3 In 1940, the Commission on Graduate Medical Education noted that chief residents should assume partial responsibility for developing conferences, seminars, and meetings but that “the basic educational purpose of the residency will not be achieved if the resident is loaded with much administrative detail.”3 Subsequent studies reported that the responsibilities of the chief resident were shifting from patient care and teaching toward administrative duties.4–8 In 1971, Steel1 reported that internal medicine chiefs spent most of their time teaching, and more than 50% reported teaching was the most enjoyable task while 40% declared administrative tasks were least enjoyable. A decade later, a survey reported that most internal medicine chiefs' time was spent on administrative tasks and that job satisfaction was inversely proportional to the amount of administrative responsiblitites.4 A 1992 review reported that administrative activities were the most important tasks of the chief resident in family medicine.6 In pediatrics, Kim et al7 reported that between 1972 and 1992 there was a substantial increase in pediatric chiefs' administrative duties and a decrease in teaching/clinical duties.

This change from clinical and education leader to administrator may have implications for the ability to recruit candidates for the chief position. The goal of our study was to investigate the current role of pediatric chief residents from the perspective of both the chiefs and their program directors.

We surveyed chief residents and program directors in US pediatrics programs in April and May 2008 via an e-mail survey. E-mail addresses were obtained from program websites and the list of programs was obtained from the Association of Pediatric Program Directors website. All available program directors and chief residents were sent the survey. Responses were deidentified and they were not linked to the program name or physician's name. Survey questions focused on the relative importance of chiefs' administrative, clinical, and educational activities. Questions for chief residents asked about the factors that motivated respondents to become chief residents, their job satisfaction, and future career plans. The Institutional Review Board of the University of South Florida approved the study.

We received responses from 127 program directors and 101 chief residents. Eighty-three percent (78/84) of the chiefs were postgraduate year-4 residents, 55% (55/100) of the responding programs had 30 to 60 residents, 60% (61/101) of the programs were university-based, and 32% (32/101) were community-based with a university affiliation. All US geographic regions were represented. Nearly all program directors and chief residents noted that administrative and educational tasks were the most important parts of the chief residents' role and about one-fourth (20% [20/101] of chiefs and 27% [34/125] of directors) felt that research was an important component of the role (figure).

Program directors and chiefs agreed that the chief's most important administrative duties were troubleshooting and on-call scheduling (table 1) and that the chief's most important educational duty was to function as a resident advocate and liaison between the residents and staff (table 2).

More chiefs (51%, 51/101) than program directors (39%, 49/125) stated that supervision of residents and students on the inpatient units was an important component. Program directors overestimated their chiefs' participation in research activities, which include conducting research, writing manuscripts, and presenting at meetings.

Discrepancies were seen in the 2 groups' perspectives of workload and professional development. Program directors were more likely to report that chiefs had a balanced workload (81% [98/121] versus 68% [68/100]) and that chiefs were able to further develop clinical skills and to effectively cope with stress and burnout.

When asked about the importance of various factors in their motivation to become a chief resident, chief resident respondents stated that the development of skills related to leadership was most important, followed by teaching and clinical skill development, administrative skill development, and plans for a career in academic medicine, as well as personal reasons. Eighty percent (71/89) of chief residents indicated the position met their expectations, but only 74% (65/88) reported they would choose to become chief again. Upon completion of the chief year, 43% (38/88) were entering hospitalist or outpatient practice, 35% (31/88) of respondents were planning to enter a fellowship program, and 17% (15/88) planned to enter academic medicine.

Residents reported the most significant difficulties faced during their chief year included a lack of support for administration and scheduling responsibilities, insufficient time for clinical/educational duties and research, having too many duties, and difficulties with conflict resolution between faculty and residents.

Chief resident and program director respondents agreed that administration and teaching were the most important components of the role. The findings also suggest that there may be an imbalance between the administrative, service, and education and research aspects of the chief resident's role. Administrative tasks are a significant component of the chief residency. Both survey groups viewed administrative tasks such as scheduling as the least satisfying part of the job and reported a lack of adequate support for these components of the chief's role. Many factors appear to contribute to the increasing administrative demands on chief residents, including promoting adherence to Accreditation Council for Graduate Medical Education duty hour limits and residents' interest in balancing professional and personal demands,9 which may increase the complexity of the scheduling component of the role.

Although chiefs and program directors were in agreement on many issues, significantly more program directors felt the chiefs' workload was balanced and that chiefs had the ability to further develop clinical skills and cope with stress and burnout. Chief residents reported that their service role was more important. This disparity may indicate a lack of communication, with program directors potentially underestimating the administrative demands placed on the chiefs. The difference between the percentage of chiefs indicating a desire for an academic career and those ultimately pursuing an academic position or entering fellowship suggests that the experience may negatively affect their perception of an academic career and is concerning for the future leadership of academic pediatrics.

Discrepancies between program director and chief perceptions of the chief resident's role suggest a need for clearly delineated position descriptions and ongoing discussions regarding specific goals and expectations. It is critical that chief residents and program directors have ongoing communication, meet routinely to discuss role-related issues, and facilitate ongoing clarification of responsibilities and expectations. Both should engage in ongoing active feedback to ensure the experience is positive and meets expectations. Programs should provide a position description that delineates basic duties; this description could be modified based on the specific chief's career goals and expectations.5 A position description also can serve as a framework for a discussion of roles and expectations during the year. Leaderships of pediatrics programs could empower the role of chief to enhance his or her effectiveness and clarify key leadership roles.10 Finally, programs could provide more administrative support for their chiefs to allow more time for teaching and clinical duties. Collectively these changes would make the chief resident year a fulfilling experience and an opportunity for the chief to provide a meaningful contribution in teaching and clinical care during this very important training year.