Management in residency training

Physician Executive, July-August, 2005 by Andrew M. Eisen

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.