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35 Managing theFamily Medicine Center
417
2days before the appointment. This approach can be used in
a way that still promotes continuity. For example, at the
University of North Carolina Family Medicine Residency
[29], 30% of appointments are “frozen” and only “thaw” to
be available for patient scheduling a few days in advance.
However, the thawed appointments are still only to be scheduled with continuity patients of the clinician. The appointment slot is only opened up to non-continuity patients if it is
not lled by the day of the appointment. The clinic adjusts
appointment templates strategically based on individual clinicians’ access and continuity needs, such as by opening
appointments to non-continuity patients sooner if a clinician
has good continuity but poor access.
By using a combination of approaches for improving
access and continuity, the two can be simultaneously
improved. Improving continuity can also improve future
access, as non-continuity clinicians often are less prepared to
address more of the patient’s issues in the same visit and may
have the patient return shortly to see their PCC.Patients may
prioritize access over continuity or vice versa depending on
the situation, and scheduling scripts that offer both options,
but with priority for continuity when possible, are helpful to
balance between the two.
Comprehensiveness andCare Coordination
Clear systems for care coordination within the clinic are
important to provide appropriate resident coverage for inbox
messages, rell requests, follow-up of abnormal test results,
patient forms, etc. Some programs expect residents to check
their clinic inboxes and keep up with patient care tasks on all
rotations. Others have systems for resident inbox coverage
when residents are on rotations with infrequent clinic presence. This may be via resident practice partners or a teambased faculty attending. Some programs have expectations
for residents to address non-urgent inbox items, with a chief
resident or faculty backup for urgent issues. Standardized
workows and expectations should be clearly established
and communicated with residents and clinic staff.
Workows should also be created or revised to streamline
routing of inbox items and messages in general. There are
often ways that staff members can use protocols to address or
facilitate responses to patient requests before or without
needing clinician input. External care coordination with care
settings outside of the clinic include following up on referrals or obtaining records when patients are seen elsewhere.
These are often areas where various clinic team members
can be helpful if aided with clear workows.
Coordination around transitions of care should also be
considered. This includes how a clinic team is notied when
a patient is seen in the emergency department or hospitalized, and what the clinic’s system is for proactive outreach to
patients to coordinate follow-up after discharge. Some programs have built care transition clinics to provide in-depth,
multidisciplinary visits after hospital discharges that can
involve residents, nursing, pharmacist, and social work team
members or learners [25]. These can simultaneously train
residents in interdisciplinary care and provide opportunities
for higher levels of care for complex patients.
Resident Engagement andWorklife
intheFMC
All of the prior Building Blocks contribute to and interact
with resident engagement and worklife. Resident engagement in the clinic addresses whether residents seem to be
temporary guests passing through the clinic, or if they are
meaningfully integrated into the clinic and empowered as
co-leaders. All residents need to learn skills in quality
improvement and working with clinical teams, but they further benet from learning skills in clinical leadership, community advocacy, health policy, and teaching. These areas
can all be potentially integrated into residents’ FMC experience, which informs residents’ clinic worklife—their experience and impressions of working in the FMC.
Participating in building high-functioning clinics gives
residents rst-hand experience in high-performing care—the
“clinic is the curriculum.” Incorporating residents meaningfully into clinic functioning begins with protecting time for
residents to participate in huddles and clinic meetings.
Creating roles for residents on clinic operations and improvement teams takes this involvement to a higher level, and provides opportunities for residents to learn about clinical
leadership, health systems, and team leadership. Some programs have residents as integral members of redesigning
clinic systems and workows toward high-performing care.
For example, at Crozer-Keystone Family Medicine
Residency [37], residents were intimately involved in the
clinic’s workgroups to redesign their patient-centered medical home model, thereby learning about practice transformation through hands-on experience. Their FMC also has a
teaching resident role where a senior resident is not scheduled to see patients but to act as a junior attending by teaching other residents, helping manage clinic ow, and
addressing urgent phone calls and lab results. Every resident
works with the practice manager in their third year to develop
leadership skills, and residents with particular interest in primary care transformation are invited to additional experiences such as state-wide improvement collaborative
meetings.
To support residents learning about clinic and how to function in clinic, many programs have created formal curricula
on clinic topics. An example is in the Oregon Health &
Science University Family Medicine Residency [38], where
418
M. Kong and C. Lyon
an introductory clinic-heavy month at the beginning of intern
year includes modules on the primary care home, EHR optimization, orientation with various clinic team members, and
introductions to population management. This is followed by
a quarterly session on topics including using data in clinical
practice, wellness and joy in medicine, access, and health literacy. Residents also complete a self-guided asynchronous
curriculum throughout residency with learning activities and
reections. The rst year is focused on the “me”—individual
clinician functioning in the FMC, including EHR best practices, how to sign out to practice partners, how to huddle and
participate in clinic meetings, shadowing patients through
clinic ow, shared decision making, social determinants of
health, agenda setting, quality improvement, billing, and population health basics. The second year is focused on the
“we”—advancing skills in team-based care and clinic operations, with topics including patient advisory councils, working with advanced practice providers, clinic access
management, shadowing faculty to learn efciency, and
meetings with clinic leadership. The third-year curriculum is
focused on the “world beyond”—larger health systems issues,
including home visits, understanding clinic budgets, teaching
junior residents and students in clinic, the medical neighborhood beyond the clinic, and community organizations.
Didactics in such curricula work best when paired with
hands-on, skills-based clinic improvement work, such as following didactics on quality improvement with sessions
where residents work with their clinic teams to review quality metrics for their panels and create PDSA cycles.
Opportunities for faculty members to shadow residents and
provide coaching on practice management or clinic ow,
such as pre-charting, agenda setting, efcient documentation, and inbox management is another way to make practice
management teaching more interactive and engaging.
Residents provide helpful insights when involved in shaping
and improving such curricula.
Quality improvement work is an opportunity to engage
residents into clinic priorities. Ideally, QI projects are relevant to the clinic’s priorities, integrated into care teams, and
sustainable [39]. In many programs, residents select QI projects based on their individual interests, which may or may
not be aligned with clinic priorities. This often contributes to
change fatigue on the part of clinic staff as resources are
invested into short-term projects that may not reect the
needs of the clinic and end after the resident graduates.
Alternatively, residents may be asked to select a project from
a list of clinic priority areas, which aligns the interests of the
residents within those of the clinic. Clinic resources and staff
could be made preferentially available for clinic-relevant
projects. Residents can co-design projects on their assigned
teams or with staff champions. When goals are aligned and
involve team members that can sustain the improvement
work beyond the resident’s presence, resident projects can be
a valuable resource for driving clinic improvement work that
may otherwise be unaddressed. For additional sustainability,
some programs have residents work on QI projects in groups,
so projects can be passed on as rotations shift and between
classes of residents. Projects are also a good opportunity for
experience with patient engagement, such as by requiring
residents to present projects to patient advisory councils or to
co-design projects with patient representatives.
Additional ways to creatively engage residents in clinic
and health system leadership are wide-ranging. At the
McGaw Northwestern Family Medicine Residency Program
at Erie Humboldt Park Health Center [8], residents have a
medical director rotation for 6weeks, where they accompany
the clinic medical director in their daily work, including
board and community meetings, and act as an assistant medical director. The clinic also holds morbidity and mortality
conferences with the clinic staff, where residents learn to
analyze patient cases for systems failures, social determinants of health, and care coordination issues. At the Family
Medicine Residency of Idaho [8], residents are required to
serve on boards of hospitals, clinics, or organizations like the
Idaho Academy of Family Physicians. They are expected to
learn about the state legislative process, legal patient advocacy skills, and write resolutions to bring to the Idaho
Medical Association. Residents have testied before the legislature and have written bills that have become law in Idaho.
The goal of such opportunities is to teach residents that they
are not just passive cogs in the larger health care system, but
are empowered as change agents at various system levels.
Effectively assessing residents’ feedback on their clinicrelated experiences, and responding to this feedback transparently and constructively, is an important way to gauge
resident worklife. Creating positive learning experiences in
the FMC is usually predicated on improving the Building
Blocks discussed in this chapter. An operationally excellent
FMC models high-performing primary care to residents,
which trains and inspires residents to use the skills they learn
in their future practice both in and outside of primary care.
Thus, in the FMC, the dual missions of patient care and education are synergistic. To quote one program director, “Good
education for tomorrow’s workforce requires excellent care
for today’s patients” [1].
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Part IX
Leadership Skills for Residency Program Directors
Practical Leadership Skills forFamily
Medicine Residency Program Directors
DavidAraujo
36
Key Points
• The residency program director’s goal is to build a program of excellence that trains the next generation of family physicians.
• Leadership is taking a team on a journey between the reality of the present and a vision of the future.
• Dening a vision of the future for the residency program
is an essential task for the program director.
• Identifying the residency’s core values and noble cause
are key to program success.
• Understanding the present reality of the residency program is necessary to take the team on a journey to the next
level.
• Leaders think and plan rst; managers respond to the
urgency of the moment.
• An important leadership skill to learn is how to manage
your time.
• Nurture and develop leadership skills in others.
• Meetings are a necessary component in the life of any
organization and need to be managed to be productive.
• Communication management is key to conveying concepts and ideas to others.
Introduction
Historically, medical training has been a process ofpassing
clinical knowledge, skills, behaviors, and attitudes from one
generation of physicians to the next through a process of
one-to-one mentorship. The modern era from the early 1900s
brought the concept of organized training programs where
groups of young doctors were mentored by seasoned physicians. Out of the mentor model, the residency training program concept developed into what we know today. Cohorts
D. Araujo (*)
Ventura Family Medicine Residency Program, Ventura, CA, USA
e-mail: David.Araujo@ventura.org
of physicians in training grouped together to learn from more
experienced physician faculty through on-the-job training
whichbecame the standard in the United States for medical
professional development. The current program requirements for Family Medicine from the Accreditation Council
for Graduate Medical Education (ACGME) state that “There
must be one faculty member appointed as program director
with authority and accountability for the overall program,
including compliance with all applicable program requirements.” In essence, the residency program director is the
leader of the residency program.
One denition of leadership is “the act of molding individuals into a team.” The role of the residency program
director is primarily dened by the ability to build a program
of excellence that trains the next generation of physicians.
The combined teamwork of faculty, residents, staff, and
stakeholders is necessary to make this a reality. The leadership role of building a team is not unique to the world of
family medicine residency programs, but it is illustrative of
the complexity of reaching a common goal within a medical
and medical education setting. One of the dening characteristics of physicians is that they have generally been leaders
and at the top of their classes during their education. Molding
a group of strong-willed individuals into a team is not a task
for the faint of heart!
The goal of this chapter is to provide insights into the
essential leadership skills and activities required of a director
of a family medicine residency program. While not all
encompassing, the emphasis is on the skills that are essential
to success. Training the next generation of family physicians
is foundational to the success of our healthcare system in the
United States. For those embarking on this journey, I applaud
your willingness to take on the wonderful and rewarding role
of a residency program director.
At its most basic level, leadership is taking a team on a
journey between the reality of the present and a vision of the
future. A leader must be able to guide the team on this journey, connecting these two ends of the spectrum: the reality of
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
R. Kellerman, G. Irwin (eds.), Graduate Medical Education in Family Medicine, Excellence in Medical Education 2,
https://doi.org/10.1007/978-3-031-70741-4_36
423
424
D. Araujo
today and the vision of the future. Being able to do this well
is the task of leadership.
The Program Director asVisionary Leader:
Building aPreferred View oftheFuture
Dening a vision for the program is a core and essential task
of the Director. For a residency program, there needs to be a
vision that denes the priorities for the existence of that program. Whether a brand new or older program with an
established history, every program needs a vision for its
future. A useful way of thinking about “vision” is to consider
it a preferred view of the future.
Program vision may develop through the development
and articulation of a mission statement, vision casting, or
similar kinds of activities. No matter the terminology, the
Director is essential in leading and guiding the development
of a program vision. This is not something to be left to a
marketing department or dismissed as just corporate gobbledygook. Paying attention to your sponsoring institution’s
mission and vision statements are an important component
of developing your program’s mission and vision statement.
Whether your residency is part of a larger healthcare system,
university, or foundation, having a dened vision that
strongly resonates with the members of your group is essential to long-term success. This is the work of the Director and
cannot be overstated as essential to the growth and development of the residency program.
Program vision grows out of shared values that are core to
everyone on the team. Dave Logan, John King, and Halee
Fischer-Wright are the authors of “Tribal Leadership” [1].
This book is a must read for any aspiring program director.
The language of Tribal Leadership centers around the concept that people working together in a group of about 20–150
people constitute a tribe. This exactly ts the size of most
residency programs in the United States. You know who is in
your tribe when you are most likely to say hello to them by
name if you meet them in the halls or while walking down
the street. In the chapter titled Core Values and a Noble
Cause, the authors describe how the developmental process
of dening core values is often transformative for
organizations.
The residents, support staff, and faculty all form a tribe.
This is the group that denes the core values for the organization. The process of developing core values will take time
and effort but cannot be shortchanged. “Tribal Leadership”
describes the ve stages of tribes, going from Stage One
through to Stage Five. Essentially, Stage Four and Five organizations are those that have developed strong cultural values
and a noble cause for their existence.
…the two most important aspects of owning Stage Four: identi-
fying and leveraging core values, and aligning on a noble cause.
Everything else the tribe does should be sandwiched between
these constructs. Projects, activities, initiatives, and processes—
unless they are fueled by values and reach toward the tribal
vision—should either be rethought until they are consistent with
these guiding principles, or pruned. ([1], p.145)
Shared core values might be expressed in words such as
family, commitment, patient care, trustworthiness, and honesty. A noble cause “is the direction where it’s (the tribe)
headed. A noble cause captures the tribe’s ultimate
aspiration.”
Inherent in the development of shared values and a noble
cause is that this can only take place in the context of a team
(or tribe, in the language of Logan, King, and FischerWright). One of the core principles I have operated from in
the leadership of a residency program is that the team is
stronger than the individual. All the faculty members should
know that the team and development of a family is more
important than any one individual. This then is the essence of
a successful residency program; development of a team that
has coalesced around a shared vision for the future, a noble
cause that naturally grows from shared core values. This is
the rst and foremost task for the Program Director.
Developing a shared set of core values and a resultant
vision takes place over time. Setting aside a day for a faculty
retreat is an ideal way to initiate the process of vision formation. Holding the retreat off-site is a way of getting your team
away from the demands of work and encouraging a focus on
the development of your core values. Develop an agenda and
do pre-work. Come to the retreat with prepared ideas on the
core values for your residency program as a way to jump
start the discussion. Start your time together with a session
that allows everyone to think outside of their normal ways of
processing information and working together in a group.
Liberating Structures https://www.liberatingstructures.com/
provides a different way of approaching how small groups
think and form ideas [2]. Use the suggestions from this online resource to kickstart small group discussion around
dening your core values. Develop a goal for the retreat,
such as, “By the end of today, we will have developed a set
of shared core values and written a mission/vision statement
for the residency program.” In my program, we have generally had a faculty retreat on an annual basis to review our
mission and vision, and then deal with current priorities for
the program. These have been auseful team building event
and has helped develop opportunities and plans for the
future.
It is wise to involve the residents in the process of developing a set of core values and mission statement for the program. While they will not have the longer view in mind as
they are only in the program for 3 or 4years at the most, they
are able to provide a lens on the impact of the stated values
on themselves and their peers. Incorporate their input into
the vision and mission statement for the program.
36 Practical Leadership Skills forFamily Medicine Residency Program Directors
425
Once you develop succinctand to-the-point core values
and amissionstatement, share them widely with your team
and residency program. Make sure that everyone has bought
into them. Use them at meetings to guide decision making
and to make sure that everything you choose to do aligns
with your core values and mission. When everyone can verbalize your core values and mission statement from memory,
you know that you have made a true impact on your
program.
For the family medicine residency program director,
vision casting and development takes place within the context of understanding the mission of Family Medicine as a
discipline. In your role as director, you should understand the
core values of Family Medicine and articulate them frequently to your faculty and residents. Joining the Association
of Family Medicine Residency Directors (AFMRD) https://
www.afmrd.org should be high on your list of priorities.
Attending the annual Residency Leadership Summit (RLS)
where you can marinate with your fellow program directors,
hear about innovation in the specialty, and become rejuvenated about the mission and vision of the specialty should be
on your list of priorities.
Developing your program’s core values and mission statement is arguably the most important work of the program
director. With these in mind, you and the program will ourish for years to come.
The Program Director asaRealist:
Understanding theCurrent Landscape
The program director must be able to take the team on the
journey between the reality of the present and vision of the
future. There are a number of venues and opportunities to
take a pulse of the present reality of your program. Some of
these are tools required by the ACGME such as the Program
Evaluation Committee (PEC), the annual Resident
Surveyand Faculty Survey, and the annual Self-Study done
as part of the accreditation process. These are not the only
ways to determine the current state of the program and you
and the faculty and resident leadership of your program
should use your creativity to devise other tools for program
evaluation.
Program Evaluation Committee: “The Program Director
must appoint the Program Evaluation Committee (PEC) to
conduct and document the Annual Program Evaluation as
part of the program’s continuous improvement process” [3].
This is your opportunity as program director to involve committed faculty and residents in the process of reviewing your
program in its present state. It can be difcult to hear critical
feedback from residents in particular, but is necessary for the
growth of the program. The process in our program has been
to review past program evaluations, ACGME resident and
faculty surveys, performance on the In-Training Examination,
American Board of Family Medicine (ABFM) (http://www.
theabfm.org) board examination pass rates from prior years,
graduate surveys, and in-house surveys of residents and faculty on particular issues of identied importance. This is
probably your most rich process in understanding the present
reality of your program. The PEC work product is an Annual
Program Evaluation, which is to be discussed with the faculty and residents and submitted to the DIO of your sponsoring institution.
ACGME Resident Survey and Faculty Survey: On an
annual basis, the ACGME will send surveys to your residents
and faculty with a set of questions developed by the ACGME
staff and residency review committees. The answers are
scored and provided to you as the program director, with
comparisons to all other programs in the United States in
your specialty. Over the years that the ACGME has used this
survey tool, there have been several iterations of the questions. While there are some concerns about the validity and
intended meaning of the questions, it remains a tool used by
the ACGME in the accreditation process. It is another way of
understanding the current reality of your program through
the combined eyes of the residents and faculty.
Self-Study: “The accreditation Self-Study is an objective,
comprehensive evaluation of the residency program, with the
aim of improving it” [3]. As with all the other tools, this is a
way of organizing into one document the present reality of
the residency program. The exact method and questions to be
answered in the Self-Study are described on the ACGME
website. The self-study process is a great opportunity as a
leader to leverage the lessons and information you have
learned about your program to guide future program vision.
It also provides a basis for negotiating with your sponsoring
institution and administrative partners to procure the
resources needed to advance your program’s vision.
The methods your program uses to take a snapshot of the
present reality of your program are limited only by your
creativity. Engaging your faculty team and chief residents
in this process is important to make it useful. In our program, we have a long-standing curriculum committee. Over
the years, this committee has either been chaired by various
faculty members, associate program directors (APD), or
the program director. There are advantages and disadvantages to who leads this committee, but it serves a vital role
in reviewing our curriculum annually and planning future
curricular changes. Whether you serve as chair or not, the
program director plays a vital role in participating and
helping to guide the work of the committee. It is important
to have key faculty members who lead portions of the curriculum and residents from each year of the residency as
participants. The residents provide an “on the ground”
viewpoint of the curricular structure since they live it out on
a daily basis.
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We have used a monthly “Faculty-Resident
Communication Hour” as another means of understanding
the present reality of the residency program. Sometimes
there is a discussion of a specic current hot topic for the
program. Other sessions are used to roll out initiatives, and
yet other meetings serve as a sounding board to hear resident
concerns. The role of the program director is vital in these
meetings to guide discussion and ensure that there is a safe
environment for residents to voice their concerns. At the
same time, you should not run a complaint session, as everyone leaves at the end feeling worse than when they started.
An hour of complaints does not lead to any substantive
change. Develop a specic question that needs to be
addressed with a focus on potential solutions to avoid the
litany of complaints that leaves everyone drained. You will
need to maintain the overall vision of the program in your
head and help residents see their role in furthering this vision
and enhancing their education.
The Program Director asManager
The many facets of being a program director requires the
ability to move between being a leader and a manager. These
two roles are not the same but can often be confused in the
minds of both those in the program director role and those to
whom a program director may report, such as the Designated
Institutional Ofcial (DIO), Department Chair, or CEO of
your sponsoring institution.
A leader generally thinks and plans rst while a manager
responds to the urgency of the moment. A leader takes ideas
and moves them into images to guide the development of
individuals and programs, while a manager establishes policies and makes decisions. A leader is interested in the impact
of a vision on people and events over extended periods of
time; a manager will act quickly and their motivations are
often misinterpreted.
Learning when you need to act as a leader and when to act
as a manager requires continual personal development and
surrounding yourself with a skilled team. The training of a
physician generally promotes rapid decision making, analyzing a disparate set of facts and formulating a therapeutic plan.
This type of training does not prepare someone to be a visionary program director. That is why being a good clinician is
not the sole prerequisite for the role of program director.
The leadership role has been addressed in the section on
the program director as a visionary leader. The role as manager has several key components, which threaten to be all
consuming unless you deliberately work on development of
vision building skills. Like all things in life, these require a
balance. Both leadership and managerial skills are necessary
to the success of being a program director.
Components oftheManager Role: Personal
Time Management
Depending on the number of residents in the program, the
program director has a certain minimum amount of percent
FTE (Full-Time Equivalent) devoted to the administration of
the residency program. This is delineated by the ACGME
Program Requirements [3]. For the average size program in
the United States, which is 8 residents per academic year for
a total of 24 residents, the PD will have a minimum of 50%
FTE for administration of the program. For the new program
director, this initially will appear to be a lot of time, and one
may even wonder what you will do with all this time. Quickly
you will realize that your time could be lled with other peoples’ request for your time. Meetings, responding to e-mails,
completing reports, residents with questions, faculty with
concerns, and administrators with requests will threaten to
ll all of your non-clinical time.
An important leadership skill is to learn how to manage
your personal time. There are a myriad of books written on
personal time management and this chapter is not meant to
be the denitive answer on this subject. Rather, it is an
encouragement to quickly come to grips with the need to
have a method of managing your time, which is your most
valuable resource. If you don’t get a handle on this early in
your career, you will end up just being a manager, reacting to
the urgency of any particular situation or problem.
I recommend that you spend time guring out your style
of managing the many requests that come your way. E-mail
will threaten to be a time sink unless you tame that beast.
Delegating and learning how to assign tasks is critical for
success. Some individuals do well with having lists that they
check off when a task is completed and others use calendars
with dates for completion of tasks. The key is to nd a
method that works for you. A classic article from the Harvard
Business Review from 1974 by William Oncken, Jr, and
Donald Wass “Management Time: Who’s got the monkey?”
captures this dynamic in an analogy that every Program
Director should take to heart [4]. This quote from the article
encapsulates the issue for the Director:
The management of time necessitates that the manager get con-
trol over the timing and content of what he does. Since what the
boss and the system impose on him are backed up by penalty, he
cannot tamper with those requirements. Thus his self-imposed
time becomes his major area of concern. The manager’s strategy
is therefore to increase the “discretionary” component of his
self-imposed time by minimizing or doing away with the “sub-
ordinate” component. He will then use the added increment to
get better control over his boss-imposed and system-imposed
activities. [4]
Oncken and Wass go on to describe a very common
dynamic that occurs in any organization. The junior member
of the team goes to the senior leader and says “Hey, we’ve
36 Practical Leadership Skills forFamily Medicine Residency Program Directors
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got a problem……” They go on to describe the issue; in the
residency context it could be a resident not performing as
expected, or maybe a problem with the call system, or any
number of issues which you could well imagine. The subordinate is happy to make it the program director’s problem.
The program director knows enough about the issue to get
involved but not enough to make an on-the-spot decision.
Eventually the program director may say something along
the lines of “thanks for bringing this to my attention, let me
think about it and I’ll let you know.” So, before this exchange,
on whose back was the “monkey,” i.e., the problem? Clearly,
it was the subordinate’s monkey but now, after the exchange,
the monkey has been transferred to the program director’s
back. All of a sudden, the program director now has to deal
with this problem and has “subordinate imposed” time
placed on his or her schedule. Clearly this is not good longterm management of the program director’s time or a plan
for success.
Development of effective personal management strategies
in order to preserve energy and time to be a visionary leader
is paramount to the success of a program director. You need
uninterrupted time to develop a vision and team cohesion.
Personnel Management
The program director will be the leader of a group of individuals responsible for the day-to-day management of the
residency program. Depending on the structure of the sponsoring institution, you may directly or indirectly oversee a
program coordinator. The job descriptions within your organization will vary but generally the program director must
have oversight of the administrative functions of the program. The ACGME program requirements state that, at a
minimum, the program coordinator must be provided with
enough time for administration of the program based on the
number of residents [3]. The average program of 24 residents
must have 100% FTE support for a coordinator. Typically the
administrative support for a residency program requires
more time than this and it usually falls to the program director to advocate for the additional personnel, time, and funds
from your sponsoring institution.
Most physicians have not been involved in managing personnel in the course of their training. This is another aspect
of the program director’s job that may come as a surprise.
The importance of nding and supporting an effective program coordinator cannot be overemphasized. Especially
with larger programs, generally those with more than 24 residents, you will need help to complete all of the necessary
administrative tasks. Having a good working relationship
with the program coordinator should be obvious from this
discussion. There are several things that you can do as the
program director to make this relationship work:
• Provide career enhancement opportunities for the program coordinator. This might include upgrading the role
to include additional administrative responsibilities that
allow for a title such as program administrator with commensurate salary.
• Encourage your coordinator/administrator to join the
Association of Family Medicine Administration (AFMA)
https://afmaonline.org
• Meet on a regular basis with the coordinator to plan, troubleshoot problems, follow-up projects, review progress,
and any prior plans.
• Encourage the coordinator to take on projects such as
grant writing, report completion, and similar types of
activities that will enhance the amount of self-imposed
time for the program director as noted in the previous
section.
• Encourage the coordinator to work at the top of their educational training in managing the human resource aspects
of the position and intersecting with the sponsoring institution administration.
• Encourage the coordinator to be an integral member of
the team by having them be part of faculty meetings and
decision making. The program coordinator can be a very
helpful window into the state of the residency and resident morale. Their input should be valued and
encouraged.
An understanding of basic human resource requirements
are a necessary part of the program director role. Policies
such as leave time, personal time off (PTO), sick leave, and
other benets provided to the residents should be understood
within the context of your sponsoring organization. At the
same time, there are both ACGME and ABFM requirements
in regards to work hour regulations and leave time, and how
it will impact any particular resident’s time in the program
and their graduation dates. As program director, you will
have to marry together sometimes conicting regulations
from your sponsoring institution and the residency accrediting bodies. You can nd current regulations regarding leave
time and FMLA on the ACGME http://www.acgme.org and
ABFM http://www.theabfm.org websites.
Another component of personnel management is leading
a process of professional development for the faculty members of the residency program. The ACGME program
requirements state that faculty members’ “participation in
faculty development related to their skills as an educator,
clinical performance, professionalism, and scholarly activities” should be evaluated [3]. While the program director
doesn’t have to directly provide the faculty development
activities, they should spearhead and make ongoing learning
in educational theory and training a regular component of
faculty life. Resources such as the Learn at ACGME website
https://dl.acgme.org provide courses, faculty development in
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assessment and evaluation, and information on the basics of
accreditation [5]. It is an excellent place to start in putting
together a faculty development program. The Society of
Teachers of Family Medicine (STFM) https://www.stfm.org
is also a great resource of faculty development materials that
can be harnessed for educating your faculty members in their
role as a teacher of family medicine. There are courses
directed toward faculty members at different stages in their
career, whether they are new to the role or have been involved
in residency education for many years [6].
Depending on the size of your program, you may be able
to have one or more associate program director(s) (APD) to
share the administrative workload. As part of the development of future leaders of the program, the program director
should spend time with the APD to help them understand the
administrative tasks of running a residency program. This
should also include helping them learn leadership skills. This
is an important opportunity to develop succession planning
for the future of the program. Helping to mold the next generation of family physician leaders is integral to the success
of family medicine and the graduate medical education
enterprise.
Meeting Management
Meetings are a necessary part of the life of any organization.
Whether one-on-one, small group, or all faculty and residents
together, you will nd yourself in charge of leading various
meetings throughout your career as program director. You
should plan on making meetings useful and productive; it’s
where progress is made toward making the vision of the program a reality. However, especially in your core faculty meetings, you need to work on developing teamwork in this
particular tribe. Remembering back to the discussion from
“Tribal Leadership,” identifying the residency’s core values
and noble cause are going to be key to program success.
However frequently you have your meetings, there need
to be ground rules in order for the core faculty tribe to
develop into a true team. Another important book for a
Program Director to read is authored by Patrick Lencioni
“The Five Dysfunctions of a Team” [7]. Lencioni uses the
story of a ctionalized technology company in trouble
despite having a great product, plenty of venture capital, and
what would appear to be a talented group of senior leadership. He takes us through the work that it takes to develop a
team that functions well, particularly in meetings, to accomplish the goals of the organization. This quote from the introduction to “The Five Dysfunctions of a Team” summarizes
this quandary of how to develop a team.
Like so many aspects of life, teamwork comes down to master-
ing a set of behaviors that are at once theoretically uncompli-
cated, but extremely difcult to put into practice day after day.
Success comes only for those groups that overcome the all-toohuman behavioral tendencies that corrupt teams and breed dysfunctional politics within them. ([7], Introduction, p.9)
The program director will face the task of building a team,
which often starts with effective meeting management. One
way to kickstart the process is by taking your faculty group
through the task of reading “The Five Dysfunctions of a
Team” [7]. The key concepts are outlined in the pyramid
model of the ve dysfunctions of teams. The bottom and
foundational concept is “the absence of trust” among team
members. Trust is necessary for team members to be open
about their mistakes and weaknesses. You have to have trust
in each other before you can begin to be vulnerable with each
other. From there you work up the pyramid to “the fear of
conict,” “lack of commitment,” “avoidance of accountability,” and nally, “inattention to results.” While this chapter is
not designed to be a comprehensive review of the concepts of
the ve dysfunctions of a team, I believe this book will revolutionize your approach to meetings and make it possible for
you to develop a true team out of your faculty group. Creating
a safe space for discourse and divergent opinions where trust
is demonstrated and valued will make your meetings productive. This is one of the most important leadership skills for a
program director to demonstrate.
Starting with “the absence of trust,” I encourage you as a
program director to develop this concept and work through
what it means to truly trust each member of the team. Without
this concept plainly out in the open, it will be impossible to
see your vision and noble cause come to fruition. Your job as
the program director is to manage your faculty meetings so
that you develop a team that will bring vision to reality.
Setting agendas and making team meetings function well
are important, but if there is no trust among the team members and ifthere is an absence of willingness to engage in
conict, then meetings will be nothing more than just reports
with no engagement in decision making. I can’t overemphasize the importance of the regular faculty meeting and in
making it a useful and engaging environment to accomplish
the work of marrying vision and reality. You should place
high value and plenty of your energy preparing for these
meetings.
There will be other meetings for which you will be
responsible to manage and develop agendas. Depending on
your program structure, you may have residency specic
committees, such as a Resident Selection Committee,
Curriculum Committee, Program Evaluation Committee,
Wellness Committee, Diversity Committee, and others.
These are great opportunities to pull in resident participation
and engage them in their own training. If you have Associate
Program Directors, this also is an opportunity for their own
leadership development by having them lead some of these
committees. Invest in the faculty as future leaders, give them
the responsibility to develop the agendas and priorities for