The Selection of Chief Residents across Residency Programs at a Large Academic Medical Center

doi:10.21203/rs.3.rs-2620674/v1

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The Selection of Chief Residents across Residency Programs at a Large Academic Medical Center

https://doi.org/10.21203/rs.3.rs-2620674/v1

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Journal Publication

published 08 Dec, 2023

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Background

Chief residents have a unique role in graduate medical education (GME). They not only connect residents with program and hospital leadership, but also advocate for the wellbeing and educational priorities of trainees. Previous studies have focused on describing the characteristics of chief residents (CRs), however little is known about how CRs are selected across GME programs.

Methods

One-on-one semi-structured interviews with all (n = 21) GME program directors at the Johns Hopkins University School of Medicine were conducted from January to March 2022. Investigators independently coded the transcripts using an inductive approach to categorize meaningful segments of text; this culminated in the identification of explanatory themes.

Results

From discussions with 21 program directors, four themes were identified: (1) identifying candidates: timing, recruitment, nominations, as well as the desirable attributes; (2) application processes: expression of intent, submission of materials, and participation in interviews; (3) selection: voting, discussions leading to consensus, and program director intimately involved in the choice(s); and (4) confidence in process and outcomes.

Conclusions

Our results provide a deeper understanding of the nuances associated with the selection of CRs. It is hoped that the descriptions of the similarities and differences across GME programs will prompt reflection about what is done at one institution such that all programs can consider what are the best practices to serve their individual goals and needs.

Graduate medical education

chief resident

selection practices

Chief residents (CRs) are integral to graduate medical education (GME). They not only serve as exemplars within their training programs, but also play pivotal roles that shape the educational experience of trainees.¹ In one of their most vital capacities, CRs serve as a bridge linking the house staff to program and hospital leadership.^1,2 Despite limited leadership experience in academic medicine,^3–5 chief residents are placed in a unique position to advocate for the wellbeing and working conditions of the house staff. In fact, a majority of chief residents continue their commitment to the training of physicians by remaining engaged in academia and careers that keep them involved in education and scholarship.^2,6

Given that chief residents are selected largely based on potential, previous studies have focused on identifying factors that may be predictive of success in the CR role.^7–10 Characteristics such as strong communication and leadership skills coupled with unfailing professionalism are believed to be essential,⁷ whereas performance on standardized exams (including U.S. Medical Licensing Exams or In-service Training Exams [ITE]) and having performed large numbers of procedures are not given as much consideration in selections for the chief resident role.^8,9 While CRs also serve as representatives of the house staff cohort, recent studies reveal that often their demographic characteristics do not embody institutional commitments to diversity, equity, and inclusion (DEI).¹¹

Few publications have explored how chief residents are selected and the literature is devoid of best practices or guidelines to assist GME programs in selecting chief residents. Because specific institutions may have educational priorities and cultures that can be distinctive, we decided to perform a qualitative study to explore all aspects related to chief resident selection practices across GME programs at a single large academic institution. This approach is different from prior studies that explored CR selection practices among different residency programs within a single clinical specialty (e.g. Pediatrics or Dermatology),^10,12 across several schools. We hope that describing the approaches employed across programs at our school will generate insights and promote reflection about how best to handle the CR selection processes.

Aim

This qualitative study explored all facets related to CR selection practices across GME programs at a single large academic institution.

Setting and Participants

This study consisted of one-on-one interviews with program directors (PDs) of GME programs at the Johns Hopkins University School of Medicine in Baltimore, Maryland. All data collection occurred between January and March of 2022.

All GME programs with chief resident roles (N = 21) were identified by departmental websites. Program directors were e-mailed an invitation to participate in an audio-recorded semi-structured video interview. In the case that a program director was unavailable, an Associate PD (APD) was interviewed. Study informants provided verbal consent at the start of the interview.

Study design

We conducted the interviews (Zoom video Communications, Inc., San Jose, California) using an interview guide (see Supplemental Content section) that was developed using an iterative process based on published literature and our own experience in GME. The interview guide was piloted with several program directors from different institutions who did not participate in the study.

Twenty-one interviews, lasting approximately 40 minutes, were conducted by one of the authors (S.M.). The interviewer (S.M.) ensured accuracy of all transcripts generated by Zoom and deidentified all transcripts before data analysis. Verbal informed consent was obtained from each participant after clarification of the study objectives and activities, and prior to interviews. This consent procedure was approved by the Johns Hopkins Medicine Institutional Review Board (IRB 00305985).

Analysis

After using an ethnographic approach during data collection, the transcripts were analyzed using this methodology.¹³ Deidentified transcribed interview was uploaded to nVivo (QSR International, Burlington, MA) for data analysis. All transcripts were read by the authors to iteratively elaborate the coding template. All transcripts were then coded by two authors; the interviewer adjudicated discrepancies as needed. The team met to discuss meaningful concepts that led to the organization of the codes into themes and subthemes. During these meetings, the authors also selected representative quotes to be shared.

Reflexivity

All authors are actively involved with one of the GME programs at our institution; P.O. serves as the APD. The authors explicitly examined our experiences with CR selections and reflected upon biases we may have brought to the study.

Representatives from all 21 GME programs with designated chief resident roles participated in the study (Table 1). Analysis of coded transcripts resulted in the identification of four main themes: identifying candidates, application processes, selection, and confidence in process and outcomes. The total number of PDs commenting on themes and subthemes, along with the number of unique quotes for each are shown in Table 2.

Identifying candidates

In explaining the ways in which candidates are recognized and considered for the chief resident roles, our informants described two groups of ideas: the processes and the desirable attributes.

Processes

The specific ways to recognize potential candidates to serve as chief residents, including the timing, recruitment methods, and nomination strategies varied somewhat across the training programs.

Timing

Within some programs, the efforts to identify potential CRs begins in the first year of residency. For others, efforts are concentrated in the year prior to assuming this role - as per the quote below:

"We ask for the [chief resident application] submissions around January or February of their post-graduate year 2.” – PD # 10.

Recruitment methods

Efforts to assess interest in the CR position were accomplished via multiple methods. Many programs inquired as part of regular meetings with trainees, and others send e-mails to all or asked select candidates to apply. Below is a representative quote:

"There's an email that goes out to all the eligible people, in their final year of training, asking anyone who's interested to apply.” – PD # 8.

Nomination strategies

Of the 21 PDs interviewed, 16 required that residents be nominated by anyone, or in some cases by specific individuals, in order to be considered for the CR role. The following quote represents this idea:

" I send an email out to all residents and faculty. It reads: 'It's time to nominate people for chief resident, you can nominate yourself, or you can nominate someone else."

– PD # 9.

Attributes

Program leadership asserted that strong clinical skills, solid teaching abilities, and specific personal qualities were highly desirable for the chief resident role.

Clinical skills

Most informants highlighted the importance of clinical performance in the consideration of future chief residents. This was assessed primarily by faculty evaluations, but ITE scores were also considered by a few programs to reflect clinical knowledge. Two representative quotes are shared below:

"We're looking for someone who [demonstrates] excellence in clinical competencies."

– Pd # 10

"We want people who [are] doing well clinically and in their ITE because we wouldn't want to give them these additional responsibilities if their main focus should be on improving their knowledge base or clinical skills." – PD # 3.

Teaching Abilities

Many were looking for chief residents who enjoyed and excelled at teaching; most also preferred those with academic career aspirations. One illustrative quote is shown here:

"One of the main qualities we look for is, are they good at teaching…And if we get feedback … that [they] go out of the way to teach, then that'll be really taken into consideration." – PD # 7

Both clinical skills and teaching abilities were admittedly recognized to be largely subjectively assessed as described by the 2 quotes below:

"We discuss among ourselves who's done a good job on service and who's done a good job teaching – but those are subjective things." – PD # 18

"To be honest, the subjective tends to trump all because we have very few objective measures… and it's really their evaluations, which, of course, are themselves subjective." – PD # 19.

Personal Qualities

Multiple personal qualities were highly valued in those being considered for CR. These included being a team player, being open-minded, professionalism, respectfulness, and accountability. Leadership skills, including being organized and a good communicator were also brought up repeatedly. Two representative quotes are shown here:

"It's someone that has to be patient with the junior residents especially early on in the year. It has to be someone that's kind and adaptable to changes." – PD # 20

"We're looking for people who are trusted and that often comes from some combination of temperament and in intellect." – PD # 16.

Dei Consideration

Most program directors voiced a desire to prioritize DEI, however many explained that they were somewhat constrained by the relatively limited diversity in the resident class. Exemplary quotes follow:

"In all that we do, [we] make sure that there's diversity, equity and inclusion across all decisions." – PD # 19

"We don't want the same type of people to do this job year after year. We want to make sure that we consider gender, race, ethnicity, etc. We have a small residency and we don't have as many people to choose from as other residencies do." – PD # 20.

Application processes

When it came to applying for CR, the processes were fairly consistent across programs and included expressing an intent to apply for the position with the willingness to participate in interviews.

Expression Of Intent

Residents were asked to submit materials, complete forms, and sometimes speak to their fellow residents about their interest in becoming CR. The informant below describes their own processes:

"Any resident who wishes to run for chief should send us an email indicating that they would like to run and a candidacy statement as to why they want the role." – PD # 15.

Interviews

In a few programs, the interview was conducted by the APDs and/or PDs, while other programs involved a larger group to meet with candidates. Most often, the interviews were described to be standardized, however a few used unstructured formats that were more free-flowing. Below are two representative quotes:

"We do round robin interviews. …The current chief residents, the program coordinators, and the program directors sit in 3 different rooms and the candidates rotate through each group." – PD # 17

"We schedule six one-on-one interviews to hear about why they want the job, how they would handle personal stress, and their organizational skills. We have a series of questions we ask [everyone]." – PD # 15.

Selection

Programs utilized a combination of methods to select finalists for CR. These include counting votes from residents and faculty members, achieving consensus through discussions by selection committees, and less frequently, the choice ultimately made by the program director. Each method was not mutually exclusive, for example, some programs utilized a combination of votes from the residents which was then reviewed by the PD and/or a selection committee prior to making a final decision.

Voting

Finalists were often determined by votes from residents and/or faculty rating as per the representative quote below:

"We have a vote or election where we poll all faculty and residents and we add up the votes - whoever gets the most wins [chief resident]." – PD # 4.

Consensus Through Discussions

Selection committees, composed of various members from program leadership, clinical evaluators, current CRs, faculty and others, engage in open and honest dialogue to pick the most appropriate candidate(s). In the quotes below, a program director describes their selection committee and the process:

"I sit down with my leadership team: my APDs, program manager, program coordinator and the current chiefs, and we discuss the candidates." – PD # 9

"[The PD] asks for input [from the] APD and the clinical competency committee, so it's a group decision. A consensus." – PD # 20.

Program Director Intimately Involved In The Choice(S)

Program leadership, primarily the PD, sometimes makes the selection of CRs after considering the input from a selection committee and/or review of votes from the faculty and residents. The following quote illustrates this scheme:

"The final say is the PD. [They] usually inform the chair and the vice chairs, but it's more of an FYI, as opposed to [them] having veto power." – PD # 6.

Confidence in process and outcomes

Most informants reported substantial confidence in their processes and outcomes with respect to chief resident selection. Two representative quotes are shown here:

"Short answer is, I like the way the process works." – PD # 16

"We tried to make the process as fair and transparent as possible. We don't advocate for any particular candidate. We let the faculty and the residents choose who they think will do the best job, and it's worked out for us each time." – PD # 21.

In this study, we unearthed many of the nuances associated with the identification of candidates, the application processes, and the selection of chief residents across GME programs. Considering that the majority of PDs were confident in their selection practices, we hope that our findings will encourage programs to reflect on their current methods and to identify best practices to serve their individual priorities and objectives.

The methods used to select chief residents are not uniform across programs and the processes are not entirely transparent. A few studies have described CR selection practices within individual GME programs.^{10–12, 14,15} These studies used surveys to gather PD responses and were limited by low response rates.^{10–12, 14,15} To our knowledge, no previous study has characterized the selection methods across GME programs. The variable selection methods we observed are likely the result of individual programmatic goals and needs, perhaps compounded by the absence of standardized methods from governing bodies such as the Accreditation Council for Graduate Medical Education (ACGME). While the ACGME provides leadership and communication resources for newly appointed CRs,¹⁶ it does not advise about best practices regarding CR selection processes.

In highlighting the facts and details of how CRs are being considered and selected across GME programs at our institution, we hope to stimulate reflection about how to do this thoughtfully. While there may not be agreed upon best practices or guidelines, prioritizing inclusivity and limiting biases expands the candidate pool and may optimize the chance of getting the strongest candidate to fill these important educational leadership roles. Because many CRs stay on in academic medicine, placing greater emphasis on equity and diversity may help to retain and expand cohorts that have traditionally been under-represented on the faculty.^17,18 Analogously, the United States Army had to reconsider their selection methods for Battalion Commanders, their first executive-level position. Surveys discovered that many in these roles were felt to be incompetent, with some described as toxic,¹⁹ and they attributed the unacceptable results to their disorganized attention to these selections. Consequently, the Army refined their approaches for selecting Battalion Commanders that recharacterized 'talent' in the candidates as the combination of knowledge, skills, and behaviors; their reimagined assessments prioritized strong communication skills, creativity, ethical leadership, and the ability to develop others.¹⁹ These attributes would also appear to be relevant for considering CR candidates. Notably, the Army’s new criteria also increased the number of minority officers, at least in part due to bias-reducing strategies that guard against reflexive practices.¹⁹

Several limitations of this study should be considered. First, this study was conducted at a single institution. While this design may limit the generalizability, qualitative studies are never generalizable. Our study of PDs across programs at our institution was a carefully chosen purposive sampling decision given that different academic institutions can have unique educational values and cultures. Second, descriptions of the CR selection process were obtained from PDs with varying levels of experience in their roles; for some their perspectives were restricted to only a few CR selection cycles but all were intimately involved with GME for lengthy periods of time. Finally, the study’s results serve to generate hypotheses about best practices for identifying candidates and selecting CRs. Quantitative studies that test various approaches would be needed to definitively identify the most effective practices.

Our results reveal extensive details related to chief resident selection practices across GME programs. It is hoped that the descriptions of the similarities and differences across the programs studied will prompt reflection about current CR selection practices at a single institution, and will encourage GME programs to consider best practices that may serve their programmatic goals.

GME – Graduate medical education

CR – Chief resident

ITE – In-service training exam

DEI – Diversity, Equity, and Inclusion

PD – Program director

APD – Associate program director

ACGME – Accreditation council for graduate medical education

Ethics approval

All methods were carried out in accordance with Johns Hopkins regulations. This study was approved by the Johns Hopkins Medicine Institutional Review Board (IRB 00305985).

Relevant guidelines – Not applicable

Informed consent to participate

Verbal informed consent was obtained from each participant after clarification of the study objectives and activities, and prior to interviews. This consent procedure was approved by the Johns Hopkins Medicine Institutional Review Board (IRB 00305985).

Consent for publication – Not applicable

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to potential identification of participants, but are available from the corresponding author on reasonable request.

Competing interests – The authors declare no competing interests.

Funding

Dr. Wright is the Anne Gaines and G. Thomas Miller Professor of Medicine supported through Hopkins’ Center for Innovative Medicine.

Author's contributions

All authors (S.M., P.O., S.W.) were involved conceptualizing this manuscript, and analyzing the data. Additionally, S.M. conducted the interviews and wrote drafts of the manuscript. P.O. was a major contributor in writing the manuscript. S.W. provided methodological support, editorial guidance and was a major contributor in writing the manuscript. All authors read and approved the final manuscript.

Acknowledgements – Not applicable

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Tables are available in Supplementary Files section.

No competing interests reported.

Download PDF

Journal Publication

published 08 Dec, 2023

Read the published version in BMC Medical Education →

Editorial decision: Major revision
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Reviews received at journal
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Reviewers agreed at journal
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Reviewers invited by journal
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You are reading this latest preprint version

The Selection of Chief Residents across Residency Programs at a Large Academic Medical Center

Status:

Journal Publication

Version 1

Abstract

Background

Methods

Results

Conclusions

Background

Methods

Aim

Setting and Participants

Study design

Analysis

Reflexivity

Results

Identifying candidates

Processes

Timing

Recruitment methods

Nomination strategies

Attributes

Clinical skills

– Pd # 10

Teaching Abilities

Personal Qualities

Dei Consideration

Application processes

Expression Of Intent

Interviews

Selection

Voting

Consensus Through Discussions

Program Director Intimately Involved In The Choice(S)

Confidence in process and outcomes

Discussion

Conclusions

Abbreviations

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

Journal Publication

Version 1