Time to Reengineer the Internal Medicine Chief Residency
Authors: Katherine A. Julian, Lurit Bepo, Catherine Reinis Lucey
Journal: JAMA Network Open (2022)

The results of the study by Garg and colleagues 1 shine a light on a legacy practice of internal medicine (IM) residencies across the country: the honorific chief resident year, typically served after completion of the formal residency program.Although the majority of chief residents surveyed would repeat their chief residency year again, respondents reported serving as primary program schedulers, and substantial numbers reported little feedback on teaching, clinical skills, or leadership skills. 1Although Garg et al 1 focused primarily on chief residents from academic centers, the chief residency year is a recognition of exemplary performance and is often considered to be a steppingstone to an academic career.The ambiguity of the role and lack of formal credentials for these future leaders is a lost opportunity both for the learners themselves and the institutions in which they work.Additionally, with medical school indebtedness steadily increasing, any year that delays entry into a position that is compensated as a practicing board-certified physician carries a high economic cost.Peers of chief residents are often hired into hospitalist positions with greater flexibility and compensation.Thus, ensuring that the types of exemplary physicians typically chosen for chief resident roles find the role to be value-added demands that we consider reengineering the year as a launching pad to leadership. Chief Residents Are Not Really ResidentsDespite the title, IM chief residents are not residents.Chief residents do not apply for a position through the National Residency Matching Program but instead are picked midway through their residency through an often opaque process.There is no formal curriculum and there are no milestone assessments, although the Garg et al 1 study shows that many do receive feedback on elements of their role.No board certification opportunity exists for successful completion of the year. Chief Residents Should Not Be AdministratorsIn many programs, the chief residency year is one designed at the completion of residency training but prior to any fellowship training or faculty appointment.For this reason, chief residents are often relied on to complete complex administrative scheduling for training programs, given their proximity to training and understanding of the staffing needs of the programs. 2This considerable reliance on chief residents for administrative tasks interferes with their ability to complete other important tasks, such as teaching and focusing on trainee well-being.There is an opportunity cost to relying on chief residents for administrative tasks.Rather than harnessing the talent of these enthusiastic future leaders for other key roles that will further develop their skills and benefit the residents in their programs (such as teaching or coaching junior residents), saddling chief residents with administrative tasks takes away from these opportunities.Moreover, the frequent turnover of chief residents means the training programs must then reorient new chief residents to complete these important administrative tasks such as program scheduling.