The Resident Development Program: Trust and Purpose

Leadership in Medicine

Most of my residency interview season last year was a blur of pant suits, airports, and morning welcome sessions. However, one interview, actually one question, has remained vividly memorable. It came from Dr. Mulholland: “Why do you want to be a leader?”

It was the first time in my 27 years that I had been asked this question point blank. After taking a moment to think, I stated that I had a passion to do as much good as possible in this world, but to do that, it was important to have a platform to influence positive change on a large scale. After I walked out of his office, I reflected on my answer and realized that I have always wanted to be a leader, but I had little to no idea how to make this happen. 

Seven months later, I was thrilled to have matched at Michigan. During intern orientation this June, we had the first session of the newly-implemented Resident Development Program, a leadership program for the residents. I recognize that intern year is about getting your feet on the ground while learning how to translate the knowledge gained in medical school to actual patient care. They imparted upon us the importance of recognizing, even as interns, that we must also be leaders. Leadership in medicine is not just about managing teams; it is about motivating those around you towards the common goal of patient care. As interns, we work with nurses, advanced level providers, upper level residents, and attendings, all with much more experience than us. Yet, we will still have to carry responsibility for patient outcomes. At night, we may be the only doctors in the hospital and every member of the team, from the nurses to fellow residents to attendings need to be able to trust us. 

In this session, we learned that an integral part of leadership, particularly at the intern level, is trust. In order to conceptualize how trust is built and to diagnose why trust can falter, we discussed four tenets of trust: competence, reliability, goodwill, and integrity.

Building Trust

Since July 1st, I have already seen and experienced all of four of these tenets in action. Not necessarily in newsworthy or life-altering ways, but in moments that have led to stronger relationships and better team dynamics.

Reliability

Halfway through the service, my senior stopped asking the interns whether we had checked vitals, supplemented the electrolytes, or gotten updated physical exams during the evening. She trusted us because we had completed these tasks without fail for the past two weeks. She knew that she could rely on us to identify changes in vitals or physical exam, and that we would notify her. For my fellow, being able to stop micromanaging the new interns freed her up to manage the floor on a more global scale, allowing her to advance her own leadership practice.

Goodwill

As the on-call intern, we were managing another service’s patient who arrived from the PACU with a hematoma in the access site. It would have been easy for our team to immediately blame the other service for improper sign-out or lack of oversight, but instead, we took a step back and reminded ourselves that each service wants the best possible outcomes for their patients. By approaching them with goodwill, we were able to work together to improve the sign out process and have implemented a new model to minimize future complications.

Integrity

My senior had asked me to check on an ICU patient housed across the hospital during the night. I had a floor full of sick vascular patients with multiple admissions coming my way. I was exhausted and remember thinking that the ICU patient was probably fine without me checking on them too, since the patient had a team of in-house residents solely dedicated to watching them. But I ran over to see the patient at the expense of delaying a low acuity admission. In the morning, the patient underwent an acute event and I was able to report a last normal physical exam that helped guide the management. At the end of the day, I knew that putting my exhaustion and worry about mounting to-do list tasks aside, checking on the patient was the right thing to do.

Competence

We all have a desire to be competent - and if you’re at Michigan, I would further speculate that you have an intrinsic focus on achievement and a drive to embody “Michigan Excellence”. I have realized that competence is a vital component of trust - showing dexterity with my knot-tying has allowed me to do more in the OR and answering questions correctly allows my senior residents peace of mind that I can recognize the red flags in my patients’ status overnight. 

However, there are plenty of times when I do not know the answer or how to perform the skill. I have found that being honest about my competence (or lack thereof) has actually helped me to maintain trust.  I’ve had multiple instances where my senior has asked me for the most recent potassium value or what time a drip was started on a patient and I simply did not remember to look. I believe that trust can be character-based and/or competency-based. In my short few months, I would argue that character-based trust is paramount. In those uncomfortable instances, I have had a momentary desire to seem competent and reliable and I have to consciously remember that it is much more important to have integrity, to reinforce the trust that has been built. It is painful in those moments to say, “I don’t know” or “I’ve dropped the ball and I haven’t checked.”   Competence can be learned, but I know that once I lose someone’s trust from a lapse in integrity, it may never be recovered. Competence can feel like a direct reflection of my value as an intern, but each interaction has reinforced my belief that integrity is one of the most important tenets in building trust in these relationships.

Reflections as an Intern

I have reflected on the Resident Development Program session and my interview with Dr. Mulholland, in the setting of beginning intern year. I used to think leaders were built in the moments of surgical grandeur – being appointed Chair of a department, giving a keynote lecture at the American College of Surgeons, or having a procedure named after you. 

I now realize that leaders are developed moment by moment, choice by choice, and the accolades are simply byproducts. It is through these minor interactions, where a nurse trusts that I will come see the patient they’re concerned about while I trust them to start the heparin drip. In those moments where my senior trusts me to check for urine output after a foley catheter has been pulled, while I trust them to relay the correct plan to me and to take my 3 AM call seriously when I am concerned about a patient’s chest pain.

These are examples of the cross-sectional views of becoming a leader on every step of the ladder. Regardless of our differences, backgrounds, and levels of training, we all share a fidelity to something higher – the ideals of patient care we are all working toward, regardless of our role or pay grade. There is no magic formula, simply a steadfast decision to follow a core set of principles again and again: to build meaningful relationships that compound to fulfill a larger vision, and to influence positive change on a large scale.

Article by Mary Shen, MD (Twitter: @mary_shen)