Coleadership Among Chief Residents: Exploration of Experiences Across Specialties

Abstract

Background

Many departments have multiple chief residents. How these coleaders relate to each other could affect their performance, the residency program, and the department.

Objective

This article reports on how co-chiefs work together during the chief year, and what may allow them to be more effective coleaders.

Methods

A phenomenological research design was used to investigate experiences of outgoing chief residents from 13 specialties at the University of Iowa Hospitals and Clinics over a 2-year period from 2012 through 2013. Thematic analysis of semistructured interviews was conducted to investigate commonalities and recommendations.

Results

Face-to-face interviews with 19 chief residents from 13 different specialties identified experiences that helped co-chiefs work effectively with each other in orienting new co-chiefs, setting goals and expectations, making decisions, managing interpersonal conflict, leadership styles, communicating, working with program directors, and providing evaluations and feedback. Although the interviewed chief residents received guidance on how to be an effective chief resident, none had been given advice on how to effectively work with a co-chief, and 26% (5 of 19) of the respondents reported having an ineffective working relationship with their co-chief.

Conclusions

Chief residents often colead in carrying out their multiple functions. To successfully function in a multichief environment, chief residents may benefit from a formal co-orientation in which they discuss goals and expectations, agree on a decision-making process, understand each other's leadership style, and receive feedback on their efficacy as leaders.

What was known and gap

A number of residency programs have co-chief residents to accommodate the number of trainees, or for other established reasons.

What is new

A qualitative study explored decision making, communication, and conflict among co-chiefs, and provided recommendations for their orientation and preparation for their role.

Limitations

Single site, small sample, and limited participation by eligible residents reduce generalizability.

Bottom line

Co-chiefs may benefit from formal co-orientation, clarification of goals and expectations, decision-making processes, and receiving feedback on their efficacy as leaders.

Editor's Note: The online version of this article contains interview questions used in the study.

Introduction

Chief residents are an integral part of residency training and teaching institutions. At the same time, their roles and responsibilities vary widely by specialty and institution.^1–5 Some institutions and national organizations conduct leadership training for chief residents.^6–14 Many specialties have multiple chief residents, or co-chiefs, due to the size of the residency program, the demand of the role, or as a historical convention. The term co-chief residents refers to an organizational structure in a single program in which 2 or more senior residents are officially recognized as leaders of the resident cohort. In some cases, their roles are divided—one may focus on rotation scheduling while the other develops educational programming. In many situations, they will have overlapping responsibilities with respect to dealing with resident issues, providing leadership to the resident cohort, and responding to faculty requests. How the co-chiefs manage these overlapping responsibilities—and how they interact with each other—sets the tone for the residents within the department.

The literature on co-chiefs is scant, and it is unclear whether and to what extent chief resident training programs focus on this subject. Berg and Huot¹ indicate that the role of chief resident is simultaneously aided and complicated when it is carried out by a group, but offer no guidance for co-chiefs. Identifying the key components contributing to effective resident team coleadership will provide needed information for current and future co-chiefs. Departments with single chiefs may benefit from this information as well. This study investigated how co-chief residents in the same department built an effective working relationship with each other.

Methods

A study with a phenomenological research design¹⁵ was conducted at the University of Iowa Hospitals and Clinics over a 2-year period from 2012 through 2013. It encompassed 15 of 19 clinical departments at the institution that had 2 or more chief residents. The focus was to investigate how effectively these co-chiefs worked with each other. The study population encompassed 35 chief residents who completed their chief year in June 2012 and June 2013. Chiefs with a co-chief received an e-mail from the author informing them of the study and asking permission to interview them. A meeting was arranged with all chiefs who responded affirmatively to the invitation. One follow-up e-mail was sent to the chiefs who initially did not respond.

Data were collected via face-to-face interviews using questions developed by the author and submitted to an evaluation expert for improvement before use. The questions are available as online supplemental material. The purpose of the research and the steps for maintaining confidentiality were explained at the beginning of each interview. All chiefs agreed to audio recording of the interview. The interviews were semistructured. The initial question list was followed with further investigation, when appropriate. Recordings were downloaded to a secure computer, transcribed by a research assistant, and reviewed by the author as needed.

The University of Iowa Institutional Review Board granted approval for conducting this study.

The author conducted a thematic analysis^16,17 of the transcripts to identify examples, experiences, issues, solutions, and commonalities. Similarities and differences regarding chief duties, responsibilities, and experiences across programs were noted. For leadership styles, each chief was asked to describe his or her own style and that of his or her co-chief and then compare them. For purposes of this study, effectiveness was measured with the question, “Was there any time you didn't want to work with your co-chief?” A yes response was considered an indicator of ineffectiveness.

Results

From a population of 70 chiefs (35 per year), 19 chiefs (27%) agreed to be interviewed. The chief residents represented the specialties of emergency medicine, family medicine, general surgery, internal medicine, neurological surgery, neurology, obstetrics and gynecology, otolaryngology, pathology, pediatrics, psychiatry, diagnostic radiology, surgery, and urology. Interviews lasted 12 to 30 minutes. Common themes were identified in the areas of orienting new co-chiefs; goals, expectations, and decision making; interpersonal conflict; leadership styles; communications; working with program directors; and feedback/evaluation. Of the 19 chiefs, 9 (47%) reported that they had not received any formal orientation, and 13 (68%) reported having had only an informal session with the outgoing chiefs. None of the respondents reported having had a conversation with leadership about how to work with a co-chief. box 1 shows sample responses from chief residents for selected themes. Practical advice and recommendations from each co-chief were also collected and aggregated, and are reported in the sections that follow.

box 1 Sample Responses From Chief Residents for Each Theme

Orientation to the Co-Chief Role

• “So first I got a mass quantity of e-mails from stuff that they had received from prior chiefs … sat down a few days later for an hour or 2 and just kind of went over … these are your definite roles, the meetings you have to attend, the things you could do, or things that I've done before.”

• “Actually it was pretty good … the chief who was doing the same things that I'm supposed to be doing arranged for a meeting for half a day where we sat down and went over everything that I'm supposed to be doing … they reserved some time for all of the 3 chiefs to sit down with the university chief and the Veterans Administration Hospital (VA) chief to get to know what they are supposed to be doing as well.”

Goals/Expectations/Decision Making

• “We kind of just bounced ideas off each other the whole year … we ran something by the other person and we always let the other person in on whatever else was going on … it was our standard practice that we always cc'd the other chief on anything that we did that was chief business related.”

• “One of the faculty took it upon himself to kind of be a mentor to us … He would meet with us every month from an administration standpoint, help us … with leadership and set goals for ourselves.”

• “It's almost defined by the role of the chief, so we split our chief [role] up into chief 1 and chief 2. Chief 1 is arbitrarily assigned all the administrative things … for 6 months you make administrative decisions like who is going to help out in clinic, and [if] there is a disciplinary or team issue that comes up, chief 1 handles that.”

Interpersonal Conflict

• “So we didn't actually have very much conflict with each other, and I think the reason is that we discussed everything at the beginning, including expectations about time off and our call … that if you don't talk about it, that's probably where most of the conflict would be.”

• “There were definitely major personality differences between us and huge differences in how we looked at being chief resident … she dealt with it as more of a disciplinarian … I really felt like our job was more to help educate the residents, make sure everyone was on track, keep them afloat, and to really kind of contribute something to the academics of the department.”

• “We came to the chief [role] as friends [but] I didn't know how she handled anger. She's the kind of person that would just not talk about it and then all of sudden she would just burst. I'm the kind of person that if I'm upset about something I would say, ‘I don't like this … we need to fix it.’ I didn't know that about her and I think she didn't know that about me.”

Leadership Styles

• “I would say that we've worked pretty well together because I think our strengths are extremely different. I'm kind of the ideas person. I don't mind taking care of heated issues … I think we were very lucky that we did not have personality clashes at all, and we're different, very different.”

• “I guess I'm more verbal and more up front about things. He is a little quieter, but I'm more likely to address the situation, pull the resident aside and address it immediately, whereas he would talk to them at the end of the day. So just formal versus informal I guess.”

Communications

• “It's almost like parenting … so that we have a similar answer if somebody goes to him or goes to me about something complicated, we are on the same page. It's just helpful when he lets me know what's going on so that we can just be on the same page.”

• “So we would page each other, e-mail each other, if 1 of us wrote an e-mail to administration we would cc each other to keep them in the loop … we spent a lot of time together in this room so we would talk a lot. If we didn't want to send e-mail, we'd text each other.”

Guidance From Program Leadership

• “We have … the team leaders’ meeting, which happens weekly. This is when all the chiefs, all the program directors … and sometimes the program coordinator would meet, and we would go through … what issues do you have that you want to discuss and then we talk … Wednesdays to go over some leadership articles and leadership skills and mitigate education issues and problem residents and some things about conflict management.”

• “Our program director kind of just gave us loose guidelines … these are some things that you may want to consider doing … this is your project—do what you want with it … our assistant program director gave us a little more framework but not a ton of guidance.”

Evaluations and Feedback

• “Nothing formal … we get feedback on how we do with case presentations at noon conference … the program director (PD) and coordinator are very good about encouraging you throughout the year by saying, ‘you’re doing a good job’ … ‘you are awesome’ … I don’t think there was anything formal that we got.”

• “I haven’t gotten any evaluation. I mean I would ask for feedback. I would go and ask people, ‘so what do you think?’ But I feel like if we had formal feedback it would be helpful.”

Advice for Future Co-Chiefs

• “I think in the beginning it would have been helpful for us to have sat down to discuss our roles and exactly what role each would play during the nonactive time versus active time. We just didn’t think about it, but it would have been helpful to do … have more of just a discussion or a game plan, but it’s hard to do that on your own in the beginning because you don’t really know what you are doing.”

• “I think they should always remember that they are 1 team—they’re not split teams—and to remember that they came into this job as friends and to keep it that way rather than think of each other as just job partners … because the job will get done no matter what, but communication is really important.”

Communication

Every interviewee reported using multiple methods of communication with his or her co-chief—e-mails, texts, pages, phone calls, and meetings. In a majority of situations, the chiefs used the e-mail copy feature to keep the other informed. Regarding the question of when a chief should inform the co-chief of new information or possible conflicts and how much to share, some chose to forward and copy every message. Nine departments had a private office for co-chiefs, which provided them with opportunities for conversations. Of the 19 co-chiefs, 2 (11%) reported meeting outside work to talk about issues in a more private setting.

Goals, Expectations, and Decision Making

Of the 19 co-chiefs, 8 (42%) formally discussed goals, 2 (11%) communicated their expectations to each other, and 2 (11%) discussed how to make decisions cooperatively. In many cases, 1 chief had goals he or she wanted to focus on, but did not verbally communicate this to the other chief. For the specialties with training longer than 4 years, the chiefs reported that they thought they already knew their co-chief and did not think it was necessary to discuss expectations. If decisions about scheduling were required, the designated scheduling chief took responsibility for making those decisions.

Interpersonal Conflict

With 1 exception, none of the co-chiefs had discussed how they would handle interpersonal conflict, and most reported that they could talk with their program director if necessary about interpersonal issues with their fellow chief. Several chiefs reported that it took several months before they learned how their co-chief would react to stress or conflict. In 2 departments, the conflict was so severe that the co-chiefs stopped talking to each other. In 2 instances, conflict between co-chiefs led to separation, complete communication breakdown, and dissatisfaction with their chief resident year.

Having their own office provided opportunity for co-chiefs to discuss issues in private, yet if there was conflict between the chiefs, sharing an office became uncomfortable. As with goals, expectations, and decision making, the co-chiefs in longer residency programs reported that they knew each other well enough to manage conflicts.

Leadership Styles

The most common leadership styles reported were accommodating, collaborative, innovative, task oriented, and people oriented. In a majority of the pairs, 1 co-chief was described as the task person—focused on rules, direct, and organizational—while the other chief was the social person—people oriented, diplomatic, and perceptive. In situations where there was a female and male co-chief (5 departments), they reported being treated equally by the residents and faculty. The sole area where roles were affected by the chief residents' sex was pregnancy; residents tended to approach the female chief regarding pregnancy matters. When 1 chief was an international medical graduate, international residents tended to make contact with that chief.

Interactions With Program Leadership

Nine of 19 interviewees (47%) reported having received no guidance or support from their program director regarding coleadership. Two chiefs noted that their assistant program director was more helpful, and 1 indicated that the first session with the program director was a detailed orientation discussing expectations and goals. Six chiefs (32%) mentioned that there were no regularly scheduled program director meetings, and 8 (42%) reported that their department had no job description or guidelines for co-chiefs. All chiefs indicated that the program director had an open-door policy for discussion of any issues.

Formal Evaluation/Feedback

No department had a formal process for evaluating the leadership performance of the chiefs, and only 1 department included a question about the chief residents' effectiveness on the program evaluation survey. All chiefs reported receiving a semiannual review, but this review did not address performance as a leader. Interviewees reported that fellow residents occasionally provided positive and constructive feedback, but feedback from the program director was infrequent and only occurred if the chief asked for it. Additionally, chiefs reported that they rarely offered feedback to their co-chief.

Discussion

Having 2 or more chiefs in the same department offers benefits but creates added challenges.

The literature on co-chief residents and leadership is sparse. However, there is literature on a parallel topic—coleadership in other areas. One study highlighted the advantages to coleadership as ongoing processes of learning from, supporting, and challenging one another as well as not working in isolation.¹⁸ Disadvantages of coleadership include the potential for interpersonal conflict, ineffective communication and competition between leaders, envy, and overdependence on the coleader.¹⁸ The results of this study corroborated the highlighted advantages and some of the challenges from the literature on coleaders. Co-chiefs reported incidents of conflict and poor communication; they did not report any incidents of competition, envy, or overdependence.

Another study found that coleaders of groups are most effective when they share an understanding about the group and have complementary skill sets and different behaviors while interacting with the group.¹⁹ The co-chiefs in this study reported that they were more effective when 1 chief was task oriented and the other was people oriented. Interviewees also reported that co-chiefs needed to understand each other's style for managing conflict before coleading, as this may have the potential to encourage group members to split the leaders, perpetuating a good leader/bad leader dynamic.²⁰ Chief residents reported that they almost never had a discussion with their co-chief regarding personal conflict and how to handle it.

This study has several limitations. While the study involved several different specialties, the sample was limited to a single institution, and only 27% of the available co-chiefs were interviewed. A third limitation is that the interview format carried a risk of social desirability bias in responses. A final limitation relates to the method used to assess ineffectiveness. The definition of ineffectiveness used in this study was very liberal. All of these limitations reduce the ability to generalize from the findings.

Recommendations

All interviewees provided suggestions to improve the working relationship between co-chiefs. Program-level interventions to help ensure the success of co-chief residencies include an orientation to the role of co-chief resident, support from the program director, and evaluation and feedback specific to the role. Key components of a positive work environment for co-chiefs include a formal orientation that addresses co-chief interactions and open dialogue between chiefs regarding goals and expectations. This helped the co-chiefs work together as a team. It was also helpful for co-chiefs to talk about personal leadership styles early on to help them understand each other's approach to leading. The findings helped produce an orientation checklist for co-chief resident orientation, a set of questions for discussion among the co-chiefs, and a set of considerations to foster success in the role of coleaders. All can be found in box 2. Program directors may find these tools helpful. Program leaders may also wish to take advantage of the knowledge and experience of outgoing chiefs and ensure that it is shared with the incoming chiefs during a formal orientation.

box 2 Orientation Outline to Enhance Communication/Collaboration Between Co-Chief Residents

Proposed Orientation Checklist for Co-Chief Residents

• □ Review job description (or create a job description, if none exists)

• □ Review pertinent policies and procedures

• □ Clarify roles and responsibilities (scheduling, educational sessions, special assignments)

• □ Goals (departmental and personal)

• □ Expectations from program director/assistant program director(s)

• □ Expectations from each other

• □ Schedule dates/times for meetings with program leaders

• □ Schedule dates/times for meetings with coordinator

• □ Methods for communicating with program leadership and coordinator

• □ Discuss how to effectively involve program leadership and the coordinator

• □ Identify development opportunities (conferences, educational sessions)

• □ Advice from outgoing chiefs

Areas to Be Discussed Between the Co-Chiefs

1. What are your goals during the year?

2. What are your expectations of each other?

3. What are your expectations of the residents? How do we communicate our expectations to them? What are the residents' expectations of us?

4. What specific roles/areas would you like to be responsible for? What roles/areas do we need to share? What roles/areas do you not desire?

5. What is the best way to communicate with you?

6. How would you describe your approach/style to leading?

7. If we should encounter conflict between us, how should we handle it effectively?

8. How should we deal with faculty issues? Resident issues?

9. How will we recognize/reward/celebrate achievements by the residents?

10. What information should we pass along to the next rising chiefs?

Suggestions for Positive Co-Chief Resident Interactions

Goals and expectations

• ▪ Try not to duplicate efforts, and keep each other informed on decisions and actions.

• ▪ Do not expect to change your co-chief's personality.

• ▪ Always remember that you are a team.

• ▪ Make a list of to-dos and split them up—divide and conquer.

Communication

• ▪ Discuss personal schedules for the year (vacation, doctor appointments, time off).

• ▪ Discuss roles for activities such as answering e-mails and responding to residents and faculty.

• ▪ Occasionally socialize outside of work to get to know each other better.

• ▪ Discuss your leadership style early on so that you will know how your co-chief tends to respond in different situations.

Decision making

• ▪ Clarify degrees of autonomy (eg, whose responsibility it is to solve resident issues, dealing with problem residents and/or faculty).

• ▪ Realize that there are 2 sides to every story; get as much information before making a joint decision.

• ▪ Discuss faculty issues together; whoever is contacted first by the faculty is the point person for resolving the issue.

Conflict management

• ▪ Be accommodating with each other. This attitude will propagate throughout the other residents and help build a culture of teamwork.

• ▪ People will snap under pressure. Don't take it personally. View conflict as an opportunity for change.

• ▪ Locate a neutral third party to help facilitate any issues between you, if needed.

• ▪ If something is bothering you, tell your co-chief. Do not let it build up. Bring it up early and discuss it.

Conclusion

Co-chief residents offer advantages, but the shared position also produces added challenges. Clear delineation of roles; a formal orientation; and a frank discussion between co-chiefs regarding goals, expectations, decision making, as well as how to address and resolve interpersonal conflicts, appear to be critical elements of a program to prepare co-chiefs for their role. Focusing on these aspects will lay the foundation for building strong working relationships between co-chiefs and enabling a successful year of cooperation.