The Art of Leading with the Right Balance as a Senior Resident

The job of a resident requires a delicate balancing act:

• between caring for patients while also fulfilling an important medical education role

• between being a leader and a follower and a teacher and a learner within the medical education hierarchy

• between developing growing autonomy and confidence as a physician while maintaining interdependence with team members and humility to learn from more experienced colleagues

• between being a thorough and sensitive patient provider and as efficient as possible in a time-stressed environment

Although every resident develops his or her own style for each of these roles, the following practical strategies were discussed in a NEJM Resident 360 discussion (How to Lead a Team on the Wards: The Art to Being an Effective Resident):

• Develop clear expectations for yourself and your team members. Be explicit about the expectations and maintain accountability. Tell your attending the skills you want to improve during a rotation and ask your interns and medical students what they want to learn.

• Pre-round on each patient to review charts and see patients. By doing so, you not only demonstrate the importance of patient care, but also have the opportunity to observe the evolution of each patient and gain first-hand knowledge of the questions that should be posed to the attending. You can also provide better guidance for interns’ presentations on rounds.

• Visit patients on rounds and teach at the bedside: Bedside rounding is the ideal opportunity to be a role model for the learners on your team. You can observe your team members’ skills in the ACGME competencies of communication (interactions with patients and families) and patient care (physical diagnosis) and provide specific and timely feedback. Teaching at the bedside does not have to be extensive — keep it short and teach something within your comfort zone (e.g., a quick look at the progression of a patient’s cellulitis; the demonstration of venous stasis changes or jugular venous distention).

• Use the transit time in between patients to teach more esoteric concepts that are relevant but not ideal to discuss in the patient’s presence. For example, after visiting a patient with Pseudomonas pneumonia, use transit time to create a list of all the antibiotics that cover Also use this time to address or clarify any uncertainties or possible concerns about patient management. For example, if you have questions about an attending’s statements or recommendations, it is important to let the attending know about your questions or concerns in a sensitive manner.

• Wrap up rounds with some key learning points for the day by formulating key questions on two or three cases each day to facilitate discussion and help make every member feel included, accountable, and relevant. Following one colleague’s suggestion, we ask students to name everything they learned on rounds that day as rounds come to an end. Often, interns also start naming things and we all discover that we covered a lot more leaning points than we thought. The result is that everyone feels good about patient care and learning. Maintaining the sense of excitement and accomplishment from continual learning can also help prevent burnout.

• Promote qualities of successful residents throughout your work with the team. The following list of habits of highly effective residents was proposed by Donna Williams, MD (Wake Forest) and others during the discussion: 

HABITS OF HIGHLY EFFECTIVE RESIDENTS

1. Joy: Residents who bring joy and enthusiasm to the team set the stage for the best learning environments. This includes having a sense of humor to help defuse the inevitable stressful times that arise on a busy service.

2. Honesty/Trustworthiness: Opportunities to display this quality include admitting when you do not know an answer, following through on tasks that you agree to take on, and giving truthful feedback.

3. Flexibility: Being able to adapt to a changing landscape minute-to-minute is essential. In addition, adapting to the strengths of the other team members is helpful.

4. Organization: Organization takes many forms, but one helpful suggestion from Shannon Martin, MD MS (University of Chicago) is to “map out rounds” ahead of time (e.g., to identify the most efficient order to visit patients to make the best use of time).

5. Prioritization: The exceptional resident is able to prioritize sick patients first, one learner’s needs versus another, and the list of tasks that must be completed. These residents are also able to prioritize their patients’ well-being above other considerations.

In summary, you can succeed on the wards and navigate the balancing act of being a resident with attention to a few basic principles:

• Model the joy you have in your work.

• Lean in to the dual roles you play as teacher/learner and leader/follower.

• Spend more time with patients at the bedside.

Dr. Adrian Umpierrez is a Hospitalist and Assistant Professor of Medicine at the Medical College of Wisconsin, Associate Program Director for the IM Residency Program, and the Director for the Bedside Procedure Service.Dr. Kathlyn Fletcher is a professor of Internal Medicine at the Medical College of Wisconsin and a Hospitalist at the Milwaukee VAMC. As an associate program director in the Internal Medicine residency program, her main role is to promote and facilitate research scholarship for the residents. She is also the faculty mentor for the VA’s Chief Resident for Quality and Safety. Dr. Fletcher’s research focus has been the interaction between graduate medical education and patient care. Topics of her work include patient perceptions of bedside rounds, the impact of discontinuity on patient outcomes, and how best to measure and allocate work between physicians.