Engaging Senior Residents as Leaders: A Novel Structure for Multiple Chief Roles

The chief resident's role encompasses administrative, academic, educational, and social responsibilities, with the goal of training future leaders while meeting the administrative needs of the residency. While many chief residents later assume leadership roles, many become “burned out” by the experience of being a chief and may not seek future leadership positions. Chief residents in a traditional structure also may lack time to pursue their own academic and clinical development. As with a limited number of chief residents, other senior residents can become disengaged from the residency process, and the program may not benefit from the skills they could offer if they had been empowered in a leadership role.

We describe a model for multiple chief resident roles that has been successfully implemented in our emergency medicine residency. By separating the responsibilities of the administrative chiefs from those of the other senior residents who manage the residency curriculum, residency research, medical student education, and other academic issues, all senior residents have leadership positions.

The existing literature on chief residents focuses on the administrative and social aspects of the position1–6 and the residents' difficult role as middle managers between their peers, the faculty, and the administration.7,8 Other articles have described the attributes and future leadership roles of chief residents.9,10 A few studies have discussed the benefits of the role of a chief resident of education11,12; one reported on an education chief resident for a surgery program who developed a curriculum that contributed to improved in-service examination scores11 and another told about a psychiatry chief resident of education who contributed to education for residents and medical students.12 

Prior to the 2009–2010 academic year, our 3-year university-based emergency medicine residency program in the southeast United States utilized a traditional chief resident structure in which 3 senior residents, selected by the program director and faculty, were charged with the ongoing administrative tasks of the residency, including carrying out the duties shown in table 1. Our concern was that many of our chief residents, who were enthusiastic and able leaders, experienced considerable fatigue and frustration during their year of service. As a result, some chiefs chose not to enter further leadership positions.

We surveyed 6 former chief residents who graduated in the 2 years before we changed our chief resident structure (the survey was approved by our Institutional Review Board). Several former chief residents reported that being a chief did not encourage them to seek further leadership roles or academic positions, and one survey respondent stated that being a chief reduced her interest in an academic or administrative career. Two former chiefs responded there were too many responsibilities for the chiefs to be successful. Based on this survey and informal conversations with residents who were not chosen to serve as chiefs, who reported they did not feel they had opportunities to contribute to the program, we determined that the “traditional” chief resident structure we were employing did not appear to optimize the potential of our chief residents, nor did it help all senior residents to develop as leaders.

To address these findings, we created a system in which several new leadership positions were created for senior residents. This system allows the program to establish multiple leaders in areas such as resident academics, journal club, and medical student education. It also allows residents to become in-house experts in their area of interest, such as curriculum organization, simulation, or ultrasonography. Senior residents are empowered to demonstrate leadership and organizational abilities to prospective employers and to lead in areas that fit their varied interests and time commitments. The roles in our program are listed in table 1. All of these responsibilities had been assigned to the administrative chief residents in the former system. In our new system, after the program director and faculty select the 3 administrative chiefs, the senior residents choose their areas of leadership in collaboration with the program director and become “resident directors” in those positions during their final academic year, allowing them to develop expertise in these self-selected domains. The specific roles are less important than the overall concept, and some individuals fill multiple positions.

The new chief resident structure is currently in its second year of implementation at our program. Currently, all senior residents fill leadership roles, creating a large leadership team that is invested in fashioning a progressive curriculum. Multiple leaders with specific domains provide the resources to advance and continually update the curriculum with active feedback from peers. Increased resident leadership has established program ownership among the seniors and buy-in from junior residents, enhancing a positive attitude among residents in the program.

To measure the program's effectiveness, we surveyed outgoing senior residents about their experiences as administrative chief or a “resident director” with leadership of a specific domain of the residency curriculum. This survey confirmed our sense that the new structure was perceived as beneficial by those who participated. All outgoing senior residents and former administrative chiefs responded that they felt the new structure helped the individual residents and the residency program meet their goals. The administrative chiefs in the new system stated that being a chief would encourage them to seek future leadership positions and contribute to their decision to enter academic medicine in the future. All resident directors stated that taking on their leadership role was either helpful or very helpful to their education, and all said they would recommend their position to other residents. All but one of the resident directors felt that participating in the new structure would encourage them to take on leadership roles in the future, and many spontaneously commented that taking on a leadership role during their final year of residency helped them feel more invested in the program. These responses are encouraging and demonstrate that the new program seems to be perceived as beneficial and is addressing some of the problems encountered in the traditional chief resident system (table 2). Limitations of our study include the fact that it is single site (ie, site with only one residency program) and that the number of participating residents is too small to draw firm conclusions.

Our model of creating multiple leadership roles for senior residents can be accomplished by motivated residents and faculty, with minimal administrative change. Our model, which appears to have strengthened the residency program while offering all senior residents opportunities to develop leadership and career potential, is a viable option for other medical residencies. It provides a dual benefit by supplying programs with multiple leaders who can work to advance the goals of a residency while simultaneously enhancing resident learning through experiential learning. It also provides a larger group of residents the opportunities to develop lifelong professional skills conducive to career satisfaction.