Culture follows values: know your values and those of your team

GME is unpredictable. For example, we recently experienced drastic fluctuations in available hospital beds. We dealt with both single day and multiweek unanticipated coverage gaps due to trainees’ personal issues. We found planning for each hypothetical situation impossible. Our team’s core values became our guide rails for making decisions about routine and unimaginable circumstances.

Our set of shared core values framed each decision, created a sense of cohesion, and organised unavoidable chaos. Each member of our team had prior experiences with leaders where they felt in-the-dark about the rationale. They felt confused or frustrated. Trust suffered. We, therefore, sought to act with transparency and found that sharing our leadership values with the programme provided trainees with expectations of what you expect of them and what they can expect of you.

The right set of values depends on the programme, the team, and the individual members of the team. We invested significant time to make certain that each member of our leadership team felt comfortable in living our values—leading by example. Nothing undermines culture more than professing one thing and practising another. Conversely, intentionally selected values that are lived daily create and maintain the culture of the programme.

To implement a set of shared values, we engaged in individual and group exercises at the leadership team and trainee levels.5 For our leadership team, we used the following:

1. Ask each member of the leadership team to identify core values (maximum 2–4).

2. From the individual core values, brainstorm a list of potential team core values. (Note: Brainstorming does not involve disagreement, rather making all ideas transparent.)

3. Create at least one example of what each value looks like in practice.

4. Generate consensus for 2–4 core values for the team.

5. Share the values and regularly highlight examples of the values in practice.

The final step was critical to our success: values must be shared with the programme and reiterated on a consistent basis. For example, our leadership team highlighted how the values supported program-level decisions or how the values were exemplified through trainee actions. We also reflected on real-time decisions to calibrate our team’s implementation of the values and build internal consistency, so that each team member, when faced with a similar problem, could make the same decision.

Leadership starts with caring: show you care

Caring drives every action among our recommendations in this paper. Caring is not just about being nice or liked; it is about doing what is best for each trainee and the programme. The trainees are the highest priority. Time and again we observed the benefits. Actively caring promoted safe learning for trainees, encouraged trainees to proactively share personal issues that may affect their work, invited conflict and criticism that facilitated programme improvement, and fostered coaching, mentoring and sponsoring relationships.6

In our experience, caring statements alone are insufficient. Programme leaders must show that they care about trainees and faculty. We brainstormed feasible, frequent, concrete acts to show caring (table 2). For example, to show that we valued our faculty colleagues, we sent weekly emails to thank faculty that attended our didactics and wrote notes to faculty that taught or were experiencing a difficult life-event (eg, a sick loved one). To demonstrate our commitment to our trainees, we scheduled weekly times to be present on rotations, texted trainees at outside facilities weekly, shared comments of appreciation on a near weekly basis, and wrote personalised notes when trainees were dealing with challenging situations. We invested time in coaching trainees that had upcoming presentations. If a trainee was asked to cover, we asked how it would affect them and collaborated to minimise negative externalities. By collectively brainstorming upfront, we created intentional ways to show how much we cared consistently. None of these actions in isolation creates a sense of caring culture; however, the aggregate can have a powerful effect on the sense of community within the programme.

Act with courage for your trainees

Programme leaders face hard decisions requiring constant risk–benefit analysis. Grounding decisions in shared values makes deciding what should be done easier but known trade-offs may still make decisions challenging. Consider the following example that we encountered several times: one trainee asks for coverage because they feel burnt out and, unbeknownst to them, the only trainee available for coverage has been feeling the same way and has covered a lot during the year. The programme leader is the only person in the decision triangle with all the information. Regardless of the decision, one trainee may feel unsupported. Moreover, decisions may be unpopular and still best for the trainees in the long run. We reminded each other that as programme leaders that care about our trainees, we must make the decisions that are best for them without concern for whether we will be ‘liked’ as leaders.

Decisions may be challenging because they require junior programme leaders to advocate fiercely for their trainees to their boss (ie, programme director), a mentor, or a potential boss or mentor (eg, hospital leadership). Trainees are their highest priority and we expected members of our leadership team to act accordingly. Leaders who are looking out for themselves should reconsider their purpose.

Most challenging decisions can wait and be made collectively. A quote (often attributed to President Dwight Eisenhower) may serve as an appropriate mantra—‘don’t just do something, stand there.’ Each of us gathered courage by taking time to think and seeking input from trusted colleagues. A supportive sidekick sometimes provided the extra-strength needed to deliver a decision or help with advocating for trainees. As discussed below, conflict is unavoidable and healthy, especially within the leadership team, and programme leaders should take steps to create strategies to make conflict productive within the team and to improve individual conflict resolution tactics and to harness the courage to engage in conflict, even when uncomfortable.

Lean into conflict: it will make your team stronger

Dysfunctional teams avoid conflict.7 Disagreement improves decision-making and contributes to personal and team growth. We need to consider multiple contexts of conflict: conflict within the leadership team, conflict with other faculty members (eg, advocating for trainees to hospital leadership), and conflict between trainees and programme leaders.

Welcoming intrateam conflict requires trust and humility. As a leadership team, we challenged each other privately, hashed out our differences, came to consensus and presented a unified front. We found that presenting a unified front for the trainees and even other faculty or programmes helped to prevent our conflicts from causing divisiveness, such as segmenting the trainees into factions based on who agrees with whom. Note, we did not hide our conflict. Instead, we maintained transparency about our disagreements and often sought trainee input based on our internal disagreements; however, the specifics of the conflict, including the individual opinions, were stored safely within our team. Ultimately, conflict within the team helped us to calibrate our collective decision-making, drive programme improvement and operate more effectively as a team.

Where conflict arose with other faculty or programmes or hospital policy/leadership, we sought to maintain transparency with the trainees so that they knew we were advocating for them. However, we approached the conflicts or potential disagreements privately to facilitate transparent discussion. Difficult conversations are frequent and we benefited from investing time to reflect on our comfort with conflict management and to improve our skills.8–10

Lastly, programme leaders should embrace opportunities to both privately and publicly receive criticism and feedback, which are forms of conflict. We actively solicited feedback by making ourselves consistently available, implementing anonymous feedback strategies, requesting targeted feedback (eg, what did you think about the format for today’s case?), and modelling feedback (eg, having a near-peer give us feedback publicly). We found some feedback hard to hear and practised (with role play) avoiding natural, defensive tendencies.11 12 We tried to channel our defensive tendencies into an opportunity to clarify or share understanding of the feedback and potentially actionable change. Defensiveness will squash the growth-minded culture13 and willingness of followers to freely deliver feedback. Negative or constructive feedback should be met with a ‘thank you’.14 15 We tried to remember that critical feedback is a gift for us as leaders and an opportunity for improvement. Showing gratitude encourages others to give similar feedback.

Time is finite for you and your trainees: protect it

Programme leaders must spend their time and allocate their trainees’ time wisely. Most trainees’ time at work is spent doing rotations necessary to become competent physicians. Programme leaders should scrutinise anything extra. This was in part from the lessons of author McKeown who talks about ‘the disciplined pursuit of less’.16 He argues that effective people and organisations are more effective when they prioritise well and avoid taking on too much. This lesson was role-modelled by a former chair of medicine who we had each observed ask the question, ‘If we are adding something, what are we going to stop doing?’ We considered the following questions to better protect time:

1. If a trainee cannot work (eg, illness), is coverage from another trainee necessary or can the faculty and remaining trainees provide safe and effective patient care?

2. Should an additional project or curriculum be mandatory? Or can opportunities be individualised? Is there sufficient faculty investment in coaching and feedback to set trainees up for success?

3. What should we stop doing?

As programme leaders, we sought to empower trainees to protect their time as well. Helping trainees decide what not to do is just as or more important than helping them decide what to do. In the next section, we make specific recommendations for how to prioritise tasks and protect time.

Set goals, prioritise and adjust accordingly

Programme leaders should set goals, establish priorities and revise them regularly. We received numerous requests and suggestions for change from faculty and trainees, and quickly realised that not all could be implemented. Unprotected time can easily evaporate with such requests, contributing to increased work without consideration of the actual benefit. For example, one trainee requested that we send out suggested readings for subspecialty didactic sessions. We could have spent 1-hour weekly coordinating with subspecialists to meet this request. Instead, we leveraged a historical perspective from our leadership team that had seen similar initiatives fizzle out because almost no one used the readings and many complained about the extra email.

Tasks pile up endlessly. Our leadership team had to leverage a system to continually prioritise tasks. We found it helpful to (1) create team and personal goals at the start of the year and revisit them periodically, (2) implement the ‘Four Ds’ of time management and (3) prioritise tasks systematically based on impact and burden.

1. Creating team and personal goals will set the stage for what is important. Writing effective goals can be challenging and we recommend using some sort of goals framework.17 18 Work-related goals may quickly consume all personal time if personal goals are not explicitly set as well. Goals should be periodically revisited and adjusted as needed. When an idea for a new initiative comes in, compare it with the set goals and determine if it should be added and if any other goals should be removed. Established goals can ensure team member accountability. For example, a personal goal for one of our team members was to return home for a child’s bedtime when not on an inpatient service, and the team helped support this and reminded the individual when they were not meeting the goal.

2. The four Ds of time management are Do, Delegate, Defer and Delete.19 With each task or problem that arises, decide where it falls. Use task categorisation among the Ds as an opportunity to take responsibility for something that falls under ‘Do’ and needs to be completed. Similarly, tasks that fall under ‘Delegate’ and need to be completed, should be seen as an opportunity to ensure accountability, after first ensuring that the necessary support and guidance exists. Consider delegating as an opportunity to empower trainees to deal with something at the lowest level. For example, when a first-year trainee asked for a weekend off while on an inpatient rotation to attend a friend’s wedding, we encouraged them to discuss it with their supervising resident/attending to see if it was feasible and, if not, to look for coverage themselves. We relied on each other to resist a natural temptation to ‘do’ everything; time really is finite.

3. We iteratively adapted a two-by-two matrix of impact and time burden (figure 1) to help us prioritise. Tasks that are low time burden and high impact should almost always be completed or scheduled (ie, Do or Delay) and, on the contrary, tasks that are low impact and high time burden should almost never be completed (ie, Delete). The remainder fall somewhere in the middle. Organisations and higher leadership can influence priorities, which may particularly limit resident leaders’ decision-making autonomy. For example, a programme may require trainees to log duty hours, even on elective rotations, to ensure ACGME compliance. ACGME requires evidence of work hour compliance and emphasises a high percentage of compliance. As a result, many programmes require trainees to log their work hours, even on rotations where work hours are never near the work hour limits. Prioritising meeting the requirements of logging work hours may not be innately impactful given the different settings.

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Figure 1

Decision matrix to help appropriately prioritize. *Organizational pressures may shift priorities outside the 2x2 decision matrix, requiring individuals to either (1) advocate for a change in organizational priorities or (2) modify their priorities to align with their organizational priorities.

Communication matters: do it often and intentionally

GME programmes have lots of moving parts and personnel, which form the perfect milieu for ineffective communication. We recommend that leadership teams develop a plan to implement effective communication strategies. The modality of communication matters and we learnt quickly that a communication strategy helped to minimise redundancy of efforts, confusion and hurt feelings. We also found that creating and revising a communication strategy helped us to maintain consistency and reduce the complexity of in-the-moment decision-making. We agreed that each of us spoke for the whole leadership team. Programme leaders communicate frequently with trainees and faculty on topics such as feedback, professionalism issues, rotation changes, coverage plans, etc. While email reigns supreme, it is useful to consider whether it is the best-suited method for the initial communication. We share our communication strategy in figure 2 appreciating that the optimal plan depends on the context of the programme. For us, the content and urgency of the matter helped determine how to communicate(figure 2). We addressed urgent issues with phone calls, finding that the real-time closed-looped communication minimised misunderstanding. If less urgent, then we selected the communication modality based on the content (figure 2).

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Figure 2

Flow diagram to help select optimal communication form.

Even with a communication strategy, we still sent lots of emails and they deserve special attention. We tried to abide by a few general rules to improve our written communication. If a team member found it difficult to write a concise email that adequately conveyed their message, they would not send it. If angry, they would sleep on it. When a decision disproportionately affected an individual or group of individuals, we made a public announcement or individual phone calls to the trainees most impacted. If an email is potentially sensitive, we recommend having at least one other colleague review prior to sending. For example, our programme director (JH) often sent emails to the programme regarding issues related to race, gender and equity throughout the year. Each time, he asked at least one of us to read it. An extra perspective can be invaluable.

There is a reason we have two ears and one mouth: listen aggressively

Active listening demonstrates caring and was a pillar of our communication strategy (table 2). Trainees and colleagues will share more with programme leaders that actively listen. The practice is no different from active listening strategies when communicating with patients.20–22 We tried to minimise distractions when talking with trainees by turning away from the computer, putting down the phone and finding a quiet place. Occasionally, distractions are anticipated. If this is the case, we said so upfront and the interruption did not come as a surprise. We tried to maintain engaged body language, responding non-verbally to a trainee’s communication. We would periodically ask questions to clarify and make summary statements to confirm understanding. These actions help to improve mutual understanding and demonstrate engagement, which we hope translates to trainees feeling more supported and likely to keep communicating. We found that practising these same strategies with each other helped us to get feedback to improve as communicators.

Preparation is respect

Programme leaders teach, coach, mentor and orchestrate programme events. Sometimes programme leaders will be thrust into an event spontaneously. For example, we occasionally had a team member tasked with going to a meeting right before (or even after) it began, making preparation impossible. Adaptability is a fundamental skill for effective programme leadership, but it should not be used as a substitute for preparation. As we have emphasised, trainees are our highest priority. Programme directors and faculty must prepare before meeting with trainees by reviewing whatever is necessary to get the most from the meeting. When scheduled to teach, we had to set aside the time to deliver high-quality education. We asked the same of our faculty and trainees and recognised that our teaching set the expectations. Asking is not the same as supporting. Our leadership team had to personally invest in helping each other, faculty and trainees prepare to deliver didactics; we assumed responsibility for the product delivered. Effective education requires preparation and ensures that we are respecting the valuable time of our trainees and faculty. Preparation was a demonstration of caring for the trainees we led.