Management in residency training.

Effective management is essential to meet the challenges of residency training and medical practice. Medical management, time management, and management of the service are all skills developed by physicians during their training.

However, management in the sense more typically used in the business world--personnel management--is a skill that receives far less attention in residency. Its value is too frequently underestimated and the development of skills in this area too commonly disregarded in what is a very intense learning experience.

In failing to emphasize training in strong management skills, residencies may be leaving trainees ill-prepared to tackle the management challenges they will face in medical practice. It will serve residents well if some fundamental concepts of personnel and team management are better integrated into their training experience.

Regardless of the scope of a particular physician's work, be it in private practice, medical administration or academic medicine, practitioners will often be members of a team working together for a common goal. In reality, physicians are often leaders of these teams, for whom an ability to effectively manage people is essential.

There are three basic functions of a manager to incorporate into residency training:

1. Team building

2. Motivation

3. Effective feedback

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Team building

For teams to work well, all members of the team need to be working together. Though this sounds obvious, it is often a step of the process that is overlooked. Communicating the team's purpose, goals, resources and challenges is the first step in accomplishing this goal.

Physicians in training, from the day they begin their residencies, become members of numerous teams. As a residency class, they may look to each other for support. As a part of the entire residency, they often work together to promote changes to the program that improve their experience.

As a ward team, they must cooperatively care for patients. This role is a new one for many residents. Often, to this point, these doctors have been in a competitive environment, always trying to prove that they are the best in the group, to excel among their peers.

Once residency begins, and throughout their professional lives, they must function as part of a team.

As their training progresses, and their level of responsibility increases, residents must learn to lead these various teams. Indeed, the concept of "graded responsibility,"--giving responsibility to residents commensurate to their experience, ability and knowledge--is required of all programs accredited by the Accreditation Council for Graduate Medical Education. (1)

Residents are now charged with getting everyone on the same page. Developing the ability to help each member of the team to understand his or her role, and to appreciate the value of others' contributions--a basic tenet of team building--is of tremendous value.

If, for example, it is not clear to the team's interns who is responsible for dictating a discharge summary if the patient's primary physician is not present, then the work may be duplicated (an obvious inefficiency) or missed entirely (a failure of the team).

If junior residents are overwhelmed with patient care and do not know whom to call for help, they may struggle, become frustrated or angry, or cut corners to get through it. In any case, patient care, as well as morale, may suffer.

Residency faculty members are charged with this same duty, but to an even greater degree. Faculty are responsible for defining residents' roles, responsibilities and priorities. In the fast-moving, intense environment of clinical medicine, residents often feel that they should sacrifice some of their didactic educational experience in order to attend to patient care matters.

Residency directors across the country, in every discipline, can relate stories of residents who consistently miss or arrive late to teaching conferences and attribute their tardiness to patient care tasks. It is essential that faculty help residents understand the importance of these educational experiences and how to utilize other members of the team to ensure that neither patient care nor medical education suffer.

Helping residents understand their roles helps them develop a sense of responsibility for their patients. They must learn to make appropriate decisions about what rises to the level of an emergency that should take precedence over their attendance at conference, and what can be deferred or delegated to other members of the team, without jeopardizing the care of the patient.

In practice, teams are everywhere. A medical practice, a call-sharing group, physicians, nurses and other ancillary health care staff, and certainly the doctor/patient/family unit are all everyday examples of teams.

In most cases, the physician is the leader, charged with, for example, helping patients understand their contribution to their own care.

Motivation

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A team accomplishes nothing if its members take no action. Providing the motivation for that action is the job of the manager. Often the greatest challenge is to motivate oneself.

Residency training creates a highly stressful, physically difficult, emotionally demanding environment. For residents working long hours at relatively low wages for their level of education (and educational debt), finding motivation is difficult.

Learning to see the long-term benefits of the experience, finding internal rewards, and being able to share these with colleagues can help make residency training not only more enjoyable, but also more productive.

Frequently, interns bemoan the burden of the routine daily tasks--the scut work--only to later voice their understanding of how much they learned from the work they did. If residents with more experience can help them see the value, their junior partners may find the workload more tolerable, and more importantly, get more out of it.

Faculty must work to keep all members of the team motivated. If one resident fails to meet his responsibilities, the team suffers by having to make up the slack. If the team fails, the patients may suffer.

It is crucial to recognize that the "When I was a resident ..." approach is not a motivational technique. It is ineffective because it divides the team and undermines the resident's self-worth. The faculty's role is to help residents find their own motivation, to discover what internal reward makes the long hours worth it.

Probably the most taxing motivational challenge in medical practice is getting patients to take responsibility for their own care. Doctors are faced every day with the task of convincing patients to take medications with unpleasant side effects, to undergo painful procedures and to modify their lifestyles in ways that may require sacrifices.

Although there may be a tendency to tell patients what to do, it may be more effective to help them come to the conclusion of what they should do on their own. (2) This ability to motivate patients and families, as well as the other members of the health care team, is among the most important skills a practicing physician may possess.

Providing effective feedback

A basic principle of improving performance is providing effective feedback. Advances in this area in residency training have been made on some levels, but more could be done.

Residents are more commonly being asked to participate in evaluation processes. Forms to evaluate clinical rotations and faculty are required, and forms for evaluating colleagues are becoming more common.

However, these documentation tools often fail to provide the real value for which they are intended. Many training program directors would acknowledge that the evaluations are only those at the extreme positive and negative ends of the spectrum, and that typically these fail to offer much substantive information or formative comment.

Frequently, they are just a list of check boxes or Likert scales that give little information as to what may be done to improve performance in the future. Residents should be offered more open-ended evaluations and encouraged to make use of them as often as possible, evaluating at all levels: their program, the faculty, supervising residents, supervisees, and themselves. As they become more comfortable with the evaluation process, more useful information may result from it.

Although one of the most common methods employed to obtain resident feedback is evaluation forms, faculty may be better served (and serve better) by relying less on the forms and more on face-to-face contact.

The paper itself is helpful as a reference and as documentation for future review, but the value of an in-person meeting with a resident is often overlooked. Subtle additions to the conversation--body language, facial expressions, and tone of voice--are lost in a written evaluation form and may provide a tremendous amount of information for a resident.

Faculty should be reminded that although negative feedback can be difficult to give, it is exactly what helps a trainee understand the areas of performance that need improvement. Senior faculty, program directors and department chairs should help faculty learn how to provide this feedback so that residents may get the maximum benefit from the interaction.

Feedback in practice is no less important. Helping patients to recognize what they are doing well and what may need improvement strengthens physician-patient relationships, ensures more effective care and may improve outcomes. Developing good feedback skills in residency can assist a physician in this role.

Implementation

Putting these ideas into practice is a significant challenge. Residencies are already burdened with detailed and extensive requirements and regulations. Obligations to document residents' experiences are substantial as well. However, creating opportunities for the development of management skills in residency may not only help trainees advance these abilities, but may actually serve some of the existing demands.

Working to create a sense of teamwork can improve communication within a program--itself a consideration by accrediting bodies--and may also generate new opportunities to brainstorm modifications to experiences that better the program.

Helping residents motivate themselves and others may make patient care more efficient and open time for more learning experiences. Effective feedback can improve everyone's performance and provides documentation of attention to outcomes. In addition, attending to the needs of residents to learn about managing people directly addresses the need to prepare them to practice in the "real world."

The variety of possible techniques for this training is as diverse as the programs themselves. Teambuilding exercises, role-playing, didactic sessions, written materials, and mentoring are but a few options.

What's most important is that programs begin to pay attention to the value of teaching our residents good management skills that serve them during residency and beyond.

Andrew M. Eisen, MD, FAAP, is associate professor of pediatrics and pediatric residency program director at the University of Nevada School of Medicine in Las Vegas. He can be reached at 702-671-2231 or [e-mail]

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References

1. Accreditation Council for Graduate Medical Education, "Essentials of Accredited Residencies in Graduate Medical Education: Institutional and Program Requirements," in Graduate Medical Education Directory 2003-2004, American Medical Association, 2003.

2. Resnicow, K., and others, "Motivational Interviewing in Medical and Public Health Settings," in Motivational Interviewing: Preparing People for Change. The Guilford Press, 2002.

Andrew M. Eisen, MD, FAAP

RELATED ARTICLE: Common--But Bad--Motivational Techniques

"When I was a resident ..."
"It's not that hard."
"What's your problem?"
"No one else is having difficulty."
"If you'd just try harder ..."
"You've got it easy."

These kinds of statements imply that there is something wrong with the resident (or patient, or other person to be motivated). Whether that is true or not, they will typically fail to motivate, and often succeed in the opposite. Terms should be more positive in tone, or an effort to get at the specific issue:

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"I know you can do this."
"Let's figure out where the difficulty is."
"What do you think is preventing you from succeeding at this?"