Stepping Up: Becoming Chief Resident

It’s a bit like going from private to sergeant overnight. Becoming Chief Resident involves a rather sudden shift from little, if any, responsibility, to directing the actions and career paths of others. The fact that these “others” are essentially your peers gives the process a more complex dimension.

Dr. Quincy Samora, Chief Orthopedic Resident at the West Virginia University School of Medicine, explains, “Becoming Chief Resident is a leap in responsibility, as well as an about-face in one’s thinking. The autonomy you are given is hoisted upon you pretty suddenly, which can be somewhat unnerving. In your third year in the OR you are trying to learn techniques with the Chief Resident, as they call it, ‘guiding your hands.’ You may be the one doing the cutting but someone is always directing your actions, including, for example, what drill and screws to use. You never do anything on your own.”

Then it might seem like someone turned up those OR lamps. “Upon becoming Chief Resident your attending will normally become your first assistant, do the retracting and give you the exposure and things you need to do your work—in essence, a role reversal. If you haven’t done so before, you must learn to think on your feet and be able to look at something and figure out how you want to treat it. If someone comes in with an ankle fracture, unlike in Post Graduate Year (PGY) 3, you are the one to decide what kind of implant will be used. After so many years in residency you’ll know 15 ways to treat something, but in the end you can only select one option for Mr. Jones or Mrs. Smith. These things can get confusing when you’re just starting out as Chief Resident, making the preoperative time more important, i.e., determining your approach, your instruments, how to position the patient, etc. Compare this with being a junior resident where all you do is retract.”

Residency is rigorous, and one is advised to check one’s lethargy at the OR door. Dr. Samora: “The time prior to being Chief is mentally demanding because you must pay attention in the OR, even if you’re just holding the retractor for five hours. I know people who have fallen asleep in the OR because they were on call and had been up all night and then had to go hold a retractor for a few hours. The main problem with this is that you miss out on what the surgeon is doing: the nuances of the procedure, as well as how this particular surgeon thinks. To be a good Chief you must learn how to be a good first assistant, anticipating the needs of the operating surgeon by figuring out his or her next step. And for that, you should be awake.”

Elaborating, Dr. Samora notes, “The most important thing is to pay close attention to the little things that the attendings do that they don’t explain. It is often difficult for them to concentrate and talk about everything they do. If you space out, then later on when you find yourself with the same type of case, you won’t be as knowledgeable as if you had paid attention. For example, we were doing a hip replacement and the hip implant looked just fine. The senior surgeon said, ‘It just doesn’t look right, ’ but he couldn’t explain why. He removed the implant and it turned out that the anatomy of the person’s hip didn’t accommodate the implant well because of the dimensions. I told the surgeon, ‘This is what makes it difficult for me…this kind of nebulous situation where there is no concrete explanation of what the problem is.’”

Exemplifying the stress involved in stepping into this new role, Dr. Samora, who was Chief Trauma Resident for eight months, says, “We have a trauma room that is dedicated to cases from the previous night. It is usually run by a trauma surgeon, who is handling a total of two rooms. This trauma surgeon handles one room, while the Chief Resident is in the other room. The cases are assigned to the rooms based on the skill level of the Chief Resident.”

“Even as Chief there are a lot of surgeries we don’t perform regularly enough to feel comfortable with, ” says Dr. Samora. “There are complex traumas in which the staff is not comfortable with you doing it by yourself…and you don’t feel comfortable either. At our program, the two trauma surgeons didn’t feel comfortable with a PGY4 in the room by himself so they required that trauma be designated a PGY5 rotation. So, if someone is in the room alone that person is the Chief. It is always stressful for the Chief Resident. Even if it is a type of case you have seen staff surgeons do 150 times the difference is that now the results—and the complications—are all yours.”

Problematic choreographing of the room flow can leave a Chief Resident twiddling his thumbs. “A Chief Resident’s responsibilities are the greatest in services where the attending surgeon runs two rooms. In situations such as this, there is usually a breaking-in period in which they do a case while you assist and then they’ll have a couple of cases where you do the procedure and they assist. Then, if they feel comfortable with your level of skill they let you run the second room.”

“Normally there is some overlap in that the staff surgeon is in there with you for the start or finish of the procedure. Generally speaking, the staff surgeon starts his or her room first and then 30 minutes later lets you start your room. Timing is really critical. I recall one of my earlier cases where I was expecting the attending to be in the room sooner than he could get there and it was just me and a junior resident. I reached the point where I was uncomfortable with the deformity and the attending was still 30 minutes from finishing his case. I stopped the operation and waited until he could come in and help.”

Part of learning the new role involves good communication with anesthesia personnel. Dr. Samora: “As Chief Resident you learn the importance of interacting with the anesthesia staff. Some anesthetists, like some orthopedists, work more efficiently than others, and finish their work faster. The most efficient anesthetists save time by determining preoperatively what sort of monitoring the patient will need in the OR. We have an anesthesia pain service, and some patients request regional anesthesia. To keep the procedures running smoothly, the most efficient anesthesiologists have blocked or catheterized the next patient before we’re finished with the previous case. Working this way helps room turnover and makes the entire day run more smoothly.”

Learning how things have changed in the training realm can make one appreciate how education has evolved. Dr. Samora: “Some surgeons will describe how it was to be Chief a number of years ago, noting that it was quite unstructured. They talk about being stuck in a room by themselves with a patient on the table and a book open to a page describing the surgery. For a variety of reasons, there is now more direct supervision of cases.”

Dr. Catherine Robertson, currently a fellow at Hospital for Special Surgery in New York, last year held the Chief Residency position at the University of California, San Diego. In assuming that post, she was struck by the need to balance the demands of the program with the desires of the residents and medical students. Dr. Robertson: “Most Chief Residents try to create an environment of responsibility where you understand that you are now leading a team and in a position to decide what the other residents are doing. For example, our trauma team had two other residents, an intern and the Chief. In trying to organize schedules and balance everything out, I had to consider issues such as how long a certain case would take, how to fit all the cases into one week, whether people were getting scrubbed in on cases they wanted, whether a given resident was sufficiently qualified to handle a certain case, etc.”

“Complicating the picture, ” continues Dr. Robertson, “is the fact that you yourself are still a resident, and that you must try to satisfy the needs of residents and attendings, who are oftentimes heading in different directions. There’s a sudden leap from resident to chief resident that places you in a supervisory role over other residents. Instead of being part of that group, you are now set apart and have different priorities. As a junior resident, I couldn’t wait to leave behind all of the ‘intern stuff, ’ such as checking labs, making the patient list, reading physical therapy notes, etc. But as a chief, I had to come right back to those things because as the leader of the team, I was responsible for the big issues and the small details.”

Regarding some of the details, she notes, “Things such as repositioning a limb or holding instruments a certain way are so natural to an experienced surgeon that they aren’t explicitly explained. I think it was as a Chief Resident that I first realized the need to watch for those details that would likely never be explained but would make the case a whole lot smoother.”

On keeping things moving in the OR, Dr. Robertson adds, “The key here is knowing who you are working with, from anesthesiologist to junior resident to scrub tech. Often an established surgeon will have a team who knows the procedures and preferences well and keeps things moving along. It’s when you have a different scrub tech or green junior resident that you really have to be on your toes to make sure things stay routine.”

Understanding that people want to be involved in the things that will direct their destiny, Dr. Robertson says, “I was well aware that the residents wanted to have input into their training. So at the beginning I sat all of the residents down and said, ‘Which procedures do you need to do more of and what are your goals for this rotation? What conferences can you attend that are in line with those goals? What is new in the literature that you find exciting?’ Equally as important is checking back with your team to make sure they are meeting their goals.”

“I also worked with a cadre of medical students because they presented at our conferences and often struggled to grasp basic orthopedic concepts. I never wanted them to sound too off base so I helped them develop their sophistication in some areas. One of the medical students’ issues is that they are generally not very capable of evaluating the literature in a critical manner; it is increasingly important that they gain such skills. Having to go through this entire process gave me a good taste of academic medicine and reminded me how much I like to teach.”

Highlighting the value of those who have gone before her, Dr. Robertson notes, “Prior to becoming Chief Resident I attended an American Orthopaedic Association emerging leaders symposium where I garnered a number of suggestions that were useful for my new role. For example, due to this symposium, once a month I sat down with the residents and discussed how they thought things were going on the service. This was helpful in many ways, and meant that we could make adjustments to improve the running of the team. I also tried to meet up with them at the end of each day in order to review interesting cases that were underway. This was particularly good in the trauma arena because some of these cases end up being unique and may be treated in a way that many people haven’t seen before. It also served as a way for others who were not scrubbed in to hear about such cases.”

As for what she found surprising about her experience as Chief Resident, Catherine Robertson says, “It was eye-opening how much of my time had to be spent doing organizational things as opposed to being in cases. I had pictured my last year as one spent mainly in the OR. I also learned that the Chief needs to take a lot of time with the team member who has the least experience, namely the intern. Then there were things that a leader does when no one else wants to do them, such as labs and verifying that the floor work is done. Those who are entering this position may not envision themselves changing dressings, for example, but get ready…you do!”

“I recommend that those in the Chief Residency position learn to give weight to things outside the OR because these things can be equally or more important, ” says Dr. Robertson. “You should also try to make changes while you’re there. Doing so will give you a real feeling of accomplishment. Don’t necessarily expect to make major changes, but it can be very satisfying to make your mark in small ways. For those individuals who might just be trying to ‘get through it, ’ I would say, ‘Commit yourself to leaving the program in better shape than when you found it.’”