What I wish I knew in residency about the chief resident role

Serving as chief resident is a prestigious role, but not everyone is cut out to deal with its responsibilities.

“It looks great on your CV, and you'll forever be remembered as a chief resident,” said AMA member Nicolas K. Fletcher, MD, who is co-chief psychiatry resident at Authority Health, in Detroit.

“But the workload is one reason to not take it on,” he said. “If your program has just one chief with 20 or so residents, you’ll have to make schedules and set up people’s paid time off and deal with all the life issues that come up on your own. That can be a lot for anyone to handle.”

In fact, Dr. Fletcher didn’t think he was chief resident material until his program director nominated him for the role.

The program director said, “If nobody votes for you, fine, but your name is definitely going on the list.”

In an interview with the AMA, Dr. Fletcher reflected on his experience about a year into this role, including how it differs from regular residency. At the top of the list: You have to think differently about yourself.

“On the surface, a chief resident serves as a liaison between the program director program and the other residents. You are the go-between for second- and third-year residents,” said Dr. Fletcher, who also serves as a delegate for the AMA Resident and Fellow Section. “But you’re also an enforcer. The program director will say, ‘Hey, I need to get the following things done,’ and expect you to get everybody in line.” 

Nicolas K. Fletcher, MD

To that end, it's important to understand the relationship you have with your program director.

“When you get into that inner circle, tough decisions need to be made,” he said. “You’re dealing with people and you're dealing with power. In fact, you’re dealing with an imbalance of power, so you need to really understand who you are and when to push and when to pull.”

Everyone considering the role has to go from thinking they and their fellow residents are peers to realizing the chief resident is in a leadership position—and that can be uncomfortable. Imagine, for example, learning that a resident was arrested for DUI.

“You will find yourself having to tell people, ‘You can't do that,’ or ‘You have one more opportunity.’ If you don't have a really good understanding of who you are and what your relationships are with people, you can lose your sense of direction and feel overwhelmed,” Dr. Fletcher said.

Along the same lines, every chief resident will be expected to be what everybody needs—but not necessarily what everybody wants. Getting through this doesn’t just require knowing all the other residents; it also requires knowing yourself.

“You're going to have to make hard decisions,” Dr. Fletcher said. “You have to know your leadership style and how you are with conflict resolution. You have to realize that you're not going to make everybody happy all the time.”

One reason for that is that you're going to be in the middle of everyone's life issues.

“If somebody gets a DUI, you're going to know about it. If somebody is struggling academically, you're going to know about it,” he said. “Being able to carry all those things in addition to being a resident yourself—and in addition to whatever your life is outside of the institution—can be really challenging.”

“It’s a different level of work than if you were to do your normal residency,” Dr. Fletcher noted. “So: Get a very clear understanding of what the administrative burden will be and understand each other’s roles so you don't get caught doing something that, say, your coordinator should be handling,” such as as a malfunctioning ID badge.

One reason to be protective of your time is that you won’t be getting paid substantially more to take on all these added responsibilities.

“You might get an extra $1,500 or $2,000 in an education stipend or a salary bump to be a chief resident. It depends on the program,” Dr. Fletcher said. “It’s not a lot.”

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“If you feel like there are things you've seen over the previous two years that could be done better, that’s another reason to become a chief resident,” Dr. Fletcher said, noting that some of that work could even be started before you get into the chief resident role.

Suggesting positive changes might boost your chances of getting the chief resident position.

“Let’s say you want to create a journal club. You don’t have to wait to become a chief resident to do that. In fact, by the time you're three or four months into your chief role, you’ll probably be too overwhelmed to take on a bunch of new stuff,” he said. “So before you apply for the position, get in touch with the people in charge and say, ‘Hey, whether or not I get the role, I think this would be a great idea.’ That will probably be another feather in your cap.”

Still, he said, “I would definitely tell you the word 'freedom’ probably isn’t one you should associate with the chief resident role. Your role is, first, to be a liaison. But after that, it is to be an advocate for the residents or a mouthpiece for the program director. You don't become chief resident and then get to create an agenda.”

“I didn't realize how good it would feel,” Dr. Fletcher said, noting that he has received numerous grateful messages from residents who had been struggling with one issue or another before they got in touch with him.

“It felt good for me to be able to say, ‘Hey, I got you. This is what you need to do,’ or, ‘Let me connect you with a resident who went through the same thing last year,’” he said. “Being able to do that—being a point of contact for people when they felt like they didn't really know what to do or how to do it—was very gratifying for me.”

Learn more about the AMA Resident and Fellow Section, which gives voice to—and advocates on—issues that affect resident and fellow physicians.