The chief thing

It starts with someone tapping you on the shoulder and looking from side to side during your second year of residency. “Psst!” they say. “I need to talk to you in confidence.”.


Kimberly Manning FACP
Kimberly Manning, FACP

It starts with someone tapping you on the shoulder and looking from side to side during your second year of residency. “Pssst!” they say. “I need to talk to you in confidence.” Immediately you start wondering:

A) Did I kill somebody?

B) Was I supervising somebody who killed somebody?

C) Am I behind on my dictations?

D) Did somebody find out that the program coordinator accidentally gave me three extra meal tickets to the cafeteria?

You follow the person—usually the program director or chairman—down the hall. The same way people follow those handbag salesdudes down some murky corridor in New York City, only to get horribly disappointed by the “totally authentic” bag that spells Chanel with an “S” and two “n”s.

But instead of getting tortured with scary pleather handbags and polyester scarves, you sit in silence across from the biggest wig you know, wondering what could have landed you there. First he or she smiles at you, kind of warm and goofy-like. Then comes the small talk about your rotation, which you try to pretend doesn't suck even if it does. Next come some ramblings about all of the times you managed not to be an assassin and do something that resembled a good job. And finally, the bigwig is out with it: “How would you feel about spending an extra year with us as chief resident?”

Whaaaat?!

Okay. Maybe you think you are halfway decent, but I'm telling you: No matter how great you are as a resident, your second year is absolutely the point where you feel the most inadequate. Something about that transition from being the intern data-miner to actually having to know what the hell is going on is terrifying. And it marks the climax of your fear of being an assassin.

I always say that being an intern is the best possible role. If you do well, you're awesome! If you screw up, you're just an intern. But being a resident? Now that's tough. You nail the diagnosis? You were expected to, so no confetti gets thrown. You miss the diagnosis? You suck.

So somewhere in the midst of that, someone representing the powers-that-be says, “Not only do you not suck, we actually trust you enough to pay you to teach others.” And in most cases, unless your personal life prohibits you from doing so, you are so caught off guard/flattered/gobsmacked that you say, “Yes.” Yes to the mess.

First things first

The first tricky part is taking boards while serving as the golden boy or girl of your residency program. Let me explain. You have been selected amongst a slew of others as one of the best the program has to offer. Your embroidered coat screams to all of the new interns during orientation that yes, you are kind of a big deal.

But.

You just finished your residency. And people who finish residencies need to take board examinations to render themselves bona fide. For folks in internal medicine, that big ol’ exam comes in August. Right at the start of your reign as the chief of the whole nest.

Sure, you were picked to be chief so you're smart. Of course. And just maybe (if you are scary-smart) you don't even bat a lash at this.

But if you are like me, it crossed your mind that you might be the first chief in all of chiefdom history to be branded with a scarlet letter “F” at the start of your year as “it girl” or “it boy.” I broke out in a cold sweat over that horrid thought. And what was worse is that I did combined training in internal medicine and pediatrics, thus doubling my anxiety. Medicine boards in August, peds boards in October. A heinous little combination.

But Hallelujah, I lived to tell—and to become certified.

The good, the bad and the disappointing

The parts that I loved about being chief resident were predictable. Teaching the residents and medical students. Serving as a liaison between the faculty and the house staff. Running morning reports and conferences. Coming up with innovative ideas.

There were also the stinky parts, like making schedules before the invention of the Excel spreadsheet. Or listening to people whine about this-and-that and that-and-this. Or calling folks in for jeopardy calls on Saturdays. But every chief sees that coming.

Yet there's this one part I can only describe as indescribable. This unpredictable thing I would guess has affected many a chief, but certainly stands out as memorable to me: discovering that the faculty members to whom I most looked up were...gasp!...mere mortals.

Some were imperfect; others were weak leaders. Some were, at times, not so noble in their professional interactions. Others were shockingly less than helpful. And in a few cases, some were just downright disappointing.

I hated seeing people's clay feet. I loved my little Pollyanna world during residency...the one where several attendings and administration leaders walked on water. In chief residency, you're in this wonky time warp between little guy and big guy. It's like suddenly being moved from the kiddie table during Thanksgiving to the grown-up table, where you discover that Aunt Clara drinks too much or Great Uncle Mike swears like a sailor and tells racist jokes. I often found myself longing for the blissful view from the kiddie table, where grown-ups are awesome and make only sound decisions worth emulating.

Fortunately, there is a flip side: discovering all of the amazing folks that you may have overlooked during residency. That quiet junior faculty member who is actually quite amazing; that tireless program coordinator who helps you put out the worst of fires; that short list of residents who always, always take one for the team without so much as a hint of complaining; that standoffish attending that seemed mean but is totally approachable; and that less-than-popular faculty member you later learn is your strongest advocate and sounding board. That part is pretty cool.

An eye toward the future

The best thing I gained in my chief year was perspective on my future. The role forced me down several paths for a little while. On Monday, I might have to be a cardiologist; on Tuesday, a pulmonologist; by Friday, an infectious disease maestro—all while wearing my Dr. Phil hat in the event of an unforeseen meltdown.

I paid attention to people and situations and my reactions to them all. And in that year, I had a ginormous ah-ha moment. All along, I thought that I would work in an office somewhere seeing a combination of adults and children while welcoming residents and students to occasionally join me. I saw a practice with mostly insured people like my folks and their families, and I imagined myself happy and fulfilled and everything else you can think of, too.

That is, until I became chief resident.

That year, I stood at the board each morning at 8:30 A.M. for Pediatrics morning report. The post-call teams would present patients, and we would teach straight from the hip. Bam! Turns out that all that frantic studying for boards paid off. It was exhilarating. I attended on the wards, and felt drunk with teaching excitement. I was rounding the way I had always wanted to round and finally discovering my own voice as a teacher. In those months, I connected with patients, especially the indigent ones. I would go home thinking about them and hoping they were okay. I would remember how their faces lit up when our team would come to see them and envelop them in the kind of respect and empathy that had become a rarity in their lives. That's when I knew.

I wanted—no, I needed—to teach. Really teach. Not just sometimes or once per week, but all the time. And not only did I need to teach, I needed to get to a sho ‘nuff and bona fide public hospital to do it. I felt drawn to the least of these. I wanted a job that would never feel like one and that could somehow also feel a little like a ministry. Instead of sending people away because they failed a wallet biopsy, I wanted to treat the folks who consistently shook me to my core, taught me the most, and touched me the most.

Did this job even exist? My chief year gave me time to realize that indeed it did.

If you know anything about public hospitals, you know there aren't a lot on the list. They are in Atlanta, New York, Miami, New Orleans, Chicago, and only a few more places. Though I was a Med/Peds-trained physician, I didn't care if I was teaching learners in the adult or pediatric setting. I just knew the environment I was looking for, and that this wasn't negotiable. Lucky for me, Grady was my only job interview that year, and the one that I continue to say “yes” to every single day. I definitely have my chief year to thank for that.

Final thoughts about chief residency

  • Campaigning to be chief resident generally guarantees you won't be.
  • The best way to become chief resident is to do a great job.
  • The year is exactly what you make of it.
  • It can be an outstanding year of discovery.
  • You find great lessons about leadership there. Even if they hurt sometimes.
  • Best of all? The chief year is a great time to linger before choosing a path.
  • It can make all the difference. It sure did for me.