The chief resident role

Authors: Claire Williams, David K Menon, Basil F Matta, Jag Ahluwalia, Arun K Gupta 

Publication date:  25 Jun 2009

Implementation of the European Working Time Directive has reduced the time doctors have available for training. Several surveys have confirmed this reduction in training opportunities: gynaecologists saw a 27% reduction in surgical activity and anaesthetists an 18% decrease in the number of cases and an 11% decrease in the number of weekly training lists.[1] [2] This reduction seems to be accompanied by a deterioration in perceived quality of life and patient care, despite a preconception that reduced hours means fewer tired and stressed doctors. Innovation is required to ensure that training opportunities are fully utilised and competencies gained within the reduced time available. Although there is a structure for the management of postgraduate medical education at a senior level, is there a case to be made for an educational advocate at trainee level?

The United States has had residency programmes for over 100 years. These programmes organise structured education and service provision, and are headed by a chief resident. Appointment to this post is often an internal department affair with non-formalised selection criteria. According to one job description,[3] the chief resident is nominated by residents and his or her roles include preparing rotas, scheduling teaching rounds, organising the educational programme, organising resident meetings, acting as resident advocate, liaising with senior staff, and orienting new residents. Personal accounts of the job often emphasise the pastoral support given to trainees and the responsibility of the chief resident to cover any gaps in on-call rotas and service provision.[4]

In the United Kingdom, the post of senior registrar is now obsolete, although there are still senior trainees who fulfil some of the roles described above. Our hospital is, therefore, exploring the introduction of a chief resident post within the main clinical directorates. The initiative is being sponsored jointly by educational leadership (the trust director of postgraduate medical education), the medical director, and clinical service managers (departmental clinical directors). The hope is that this will create a cadre of senior trainees who have reached a transitional stage such that they will benefit professionally from this sort of appointment and at the same time will contribute to the organisation and running of departments.

What does experience from the US have to show us? Programme directors placed primary importance on the administrative role of the chief resident,[5] [6] whereas chief residents themselves felt underprepared for their position with particular regard to administrative skills. A survey highlighted difficulties in working without a clear job description,[5] a point that must be carefully noted. Individual hospitals and departments must have a clear idea of what is required from local chief residents, and a rational and appropriate job description needs to be agreed before introduction of such a post. We have taken this cautionary note on board and have also tried to modify aspects of the role to make it more applicable to local needs.

For example, one important decision for individual organisations to make is whether the post should include responsibilities for organisation of rotas. In the US context, such responsibilities may lead to the chief resident having to cover unexpected absences and trainee shortages. Such an outcome is unfair and makes the role less popular. The current plan in our setting is that the chief resident, while being responsible for the trainee body as a whole, would devolve the responsibilities for rota organisation to another individual and would act as a final arbiter of the fairness of such a process.

Chief residents have been described as middle managers with four directions of responsibility: upward to the consultant body, downward to the trainee body, laterally to other middle managers, and internally to other chief residents.[6] Organisation of training will remain with the deanery, heads of school, and local specialty tutors, although within each directorate the chief resident could have some influence over the way training is implemented. The other three directions will persist, but it is likely that the interaction with the trainee body will be more in the role of a representative than as an autocratic leader. Despite these transatlantic differences in the proposed role, it is essential that the chief resident has the authority to deliver what is asked of her or him; not to provide such authority would make the post meaningless.

The role could also be a link between hospital management, the consultant body, and the community of trainees; such a link would facilitate a two way flow of information and ideas. In the context of frequent (some would say perpetual) structural reorganisation and service change, the opinions and feedback of the trainee body are essential, but often they are difficult to obtain in a coherent fashion. In addition, the lack of trainee representative involvement in the design and implementation of such changes often results in a perception by trainees that they are the subjects (or in some cases victims) of change rather than stakeholders in the process. Although ad hoc trainee representation is often sought, this is a suboptimal solution. Clinical duties and frequency of rotation make it difficult to provide a continuing representation to relevant committees.

The chief resident could, therefore, have several roles and responsibilities, depending on the model employed, but what are the benefits to the individual who takes on the post? One hope is that these individuals will become the clinical managers of tomorrow, with pre-accreditation training that takes account of their special needs as management specialists. The NHS report High quality care for all: NHS next stage review final report emphasised the requirement for management and leadership training for doctors and has led to specific posts for management training as a one year secondment within the specialist trainee grade funded by strategic health authorities in many regions around the country.[7]

Although specialist societies with an interest in leadership and management have been active for a while—for example, the British Association of Medical Managers—newer ones, such as Anaesthetists in Management, are now emerging.[8] Anaesthetists in Management has published a proposal on management skills for trainees in anaesthesia. The skills it suggests include time management, managing change, use of information, business planning, interview skills, working in committees, negotiation, and dealing with conflict and difficult colleagues. These skills are often employed by most anaesthetists, but experience in formal committee work and conflict resolution can be gained only by working at a hospital, regional, or national level. Trainee representation at specialist societies could give trainees such opportunities, but the knowledge of the workings of the NHS, organisation of training, service planning, and observing the roles available to consultants are better gained at a hospital level.

A chief resident role adapted from the US model, specific for the UK, will be a useful training opportunity and will help nurture the clinical leaders of the future, supporting the aims of Lord Darzi’s next stage review.

Competing interests: None declared.

Claire Williams specialist registrar  Addenbrooke’s Hospital, Cambridge CB2 2QQ
David K Menon professor and head  Division of Anaesthesia, University of Cambridge
Basil F Matta clinical director of perioperative care services  Addenbrooke’s Hospital, Cambridge CB2 2QQ
Jag Ahluwalia medical director  Cambridge University NHS Trust, Addenbrooke’s Hospital
Arun K Gupta director of postgraduate medical education  Cambridge University NHS Trust, Addenbrooke’s Hospital

 clairewilliams@doctors.org.uk