The Resident Voice: Identifying Qualities of Resident Leadership with a Focus Group of Second Year Residents

Background The Accreditation Council for Graduate Medical Education (ACGME) Internal Medicine Residency Program Guidelines identifies leadership as a core competency. The definition of strong resident leadership is not clearly defined. Prior studies have identified characteristics of resident leadership from the perspective of residency program leaders with little emphasis on the resident point of view. Objective This study aims to identify qualities of effective resident leadership from the perspective of Internal Medicine (IM) residents.


Objective
This study aims to identify qualities of effective resident leadership from the perspective of Internal Medicine (IM) residents.

Methods
Participants were recruited through email invitations. An online focus group with five IM residents was conducted in September 2020. The transcribed discussion was inductively analyzed using thematic data analysis.

Results
Analysis resulted in four main themes of strong resident leadership: mentorship, team ownership, communication, and emotional intelligence. All four themes were further characterized by subthemes. Being a mentor as a resident leader was described as having the ability to guide, motivate, and empower team members. Team ownership was defined as caring about team image, adaptability, and accountability for team performance. Communication skills included setting expectations, giving feedback, and utilizing closed-loop communication. Emotional intelligence was characterized as practicing empathy, psychological safety, and appreciation.

Introduction:
Internal Medicine (IM) residency in the United States is a three-year experience during which residents are expected to lead a team of physicians and medical students in their second and third years of training. This structure of physician training has led to many residents finding themselves in leadership positions by circumstance rather than by deliberate choice 1,2 .
Leadership is identified as a core competency in the Accreditation Council for Graduate Medical instead, the ACGME guidelines state "the program is expected to define its specific program aims consistent with the overall mission of its Sponsoring Institution, the needs of the community it serves and its graduates will serve, and the distinctive capabilities of physicians it intends to graduate" 3 . Prior studies have identified qualities that make an effective resident leader such as providing effective communication, team motivation, and feedback but these attributes are from the perspective of chief residents, attending physicians, and consultant companies 4-6 .
This study aims to understand qualities that contribute to ideal resident leadership from the perspective of current second year Internal Medicine residents.

Methods:
All 38 second-year residents from one internal medicine residency program at a large academic institution in Florida were invited to participate in this study. Participants were recruited through email invitations. Five residents agreed to participate. Participation was voluntary and participants did not receive any compensation. The study investigators (C.C. and D.H.) were both medical doctors and second-year Internal Medicine residents in the same residency program as the participants. The study investigators obtained verbal consent from all participants before discussions began. A one-time focus group discussion was conducted in September 2020 to explore the understanding of Internal Medicine residents of what makes an effective or "strong" resident leader. An inductive thematic analysis approach and constructivist paradigm was used to analyze the data gathered in this study with emphasis on participants' subjective experiences and interpretations 7,8 .

Data Collection
Due to the COVID-19 pandemic, an online focus group discussion was conducted by a zoomvideo meeting rather than in-person. Before the start of the focus group, the participants

Data Analysis
Qualitative descriptive methodology was used to inductively analyze the gathered data. Two investigators (D.H. and C.C.) independently coded the focus group transcript, discussed, and reconciled differences. A coding scheme was developed using a thematic approach. Transcripts were first coded line-by-line for semantic and conceptual data. Inductive reasoning was followed to sort codes and identify patterns in the data. Similarities among codes led to clustering into themes and subthemes 4 . No identifying information was collected about the participants in order to protect privacy. Only the study investigators had access to the audio recording and transcription. Two of the investigators were in the same residency class as the participants.
Reflexivity was utilized to promote open and honest conversation. The moderators were able to create a psychologically safe environment having gone through the same experiences as the participants 10 . This also facilitated in-depth analysis of the explicit and implicit meanings in the data. The University of Miami institutional review board (IRB) approved the study on September 14, 2020: IRB number MOD0041899.

Results:
Five second year Internal Medicine residents participated in this study. Data analysis resulted in four main themes used to characterize the qualities of strong resident leadership: mentorship, team ownership, communication, and emotional intelligence. All four themes were further characterized by subthemes ( Figure 1).

Mentorship
In the medical community, mentorship, defined as a partnership in personal and professional growth, is crucial to the continued development of the physician 11 . To be an effective mentor one must guide, motivate, and empower their fellow mentees. The participants emphasized these qualities of a mentor as crucial to strong resident leadership ( Figure 2).

Guidance
We began the focus group with the question, "what does resident leadership mean to you?" The very first response was "I believe leadership means guidance; it means someone that is supportive." Providing effective guidance was further classified as active guidance (i.e. setting clear goals) and passive guidance (i.e. leading by example). One participant noted at the start of 8 residency "he [the intern] is so lost that he needs some sort of figure that can guide him." This situation requires active guidance as the resident teaches the intern how to place orders, call consultants, and write notes. Passive guidance was noted to be equally as critical to effective leadership. One participant noted "we [upper-level residents] are guiding them [interns] to navigate the system but we are also teachers on how to be residents" and that teaching how to be residents is accomplished with "leading by example."

Motivation
Participants identified the ability to motivate as another key characteristic of resident leadership.
One resident stated, "I believe a leader is someone that motivates you to be a better resident overall. That motivates you to do research or to achieve your goals." This concept of encouraging individual development was reiterated by other participants as they recognized a resident leader as a person who thinks about "how can we make you [the intern] improve" and works "little by little, giving the interns more responsibilities."

Empowerment
Empowerment was identified as another element of effective leadership. As described by one of the participants, "at some point you need to allow the intern to start transitioning to be a senior." Empowerment was noted to be accomplished by building trust, assigning critical tasks, and offering visible support all of which were explicitly identified by the participants as part of the skillset of an effective resident leader.

Team Ownership
Team ownership was defined as caring about the image of the team, evaluating and adapting to the needs of the team, and assuming accountability for team failures (Figure 3).
Caring about team image Four participants noted that some of their worst experiences as interns were under the leadership of residents who would unapologetically interrupt their team members stating, "oh no, that's completely wrong". All focus group members expressed frustration when working with this type of resident leader. One participant proposed that the intention of this type of poor leadership, interrupting and discrediting other team members, is to be perceived as the most knowledgeable person on the team by making others appear incompetent.

Adaptability
Throughout the focus group, adaptability was noted to be essential to effective leadership as one participant remarked, "a leader needs to have the ability to assess the team and adapt, because every team is different." In order to be adaptable, a resident leader is forced to be "someone that is mobile and knows how to do everything in the system" so that if the need arises the leader can perform any task, from administrative paperwork commonly referred to as "scut work" to prescribing medications. The resident leader dismantles traditional power structures and recognizes that as an effective team leader, she or he must graciously perform any team task no matter how menial it seems to be.

Accountability
As the head of the team, the resident leader must take accountability for not only their own mistakes but also the mistakes of the team. One participant noted, "As a whole team when things go wrong, we [upper-level residents] have to look into ourselves and say what happened? Where did I fail us as a leader?" This requires resident leaders practice self-reflection and humility. As another participant stated, as a leader you must "recognize you're a human being and that you make mistakes when you're stressed and acknowledge this, you have to own it."

Communication
The ability to effectively communicate is essential for physicians. Successful communication is so fundamental that some residency training programs have developed curriculums dedicated to improving the communication skills of their trainees 6,12 . As a resident leading a healthcare team, clearly communicating with team members is the foundation of strong leadership. In this study, The ability to give and receive growth oriented clear real-time feedback was considered by all participants to be a crucial aspect of effective resident leadership. One participant noted frustration when her resident leader was unable to provide feedback stating "I prefer to know straightforwardly what I did wrong. Like you're doing this wrong, do it better. And I know this is the problem. But I hate when it's like, a little bit of passive aggressiveness." On the topic of feedback, participants pointed out issues with the current culture of feedback as "basically, I don't want to hurt your feelings" instead of being growth oriented and constructive. In multiple studies researchers noted that a culture of politeness often impedes honest and constructive feedback [16][17][18] . The participants pointed out that we must give "feedback beyond personality" with the understanding that feedback is the means to development. Finally, participants noted that feedback must be bidirectional, a practice that is being increasingly recognized as important for a collaborative work environment 9 . Effective leaders should not only provide growth-oriented feedback to team members but also be able to act on the feedback they receive from others. As one participant noted "...it goes both ways, it's not just us giving it [feedback] to the interns but also how can we [resident leaders] be better."

Emotional Intelligence
Emotional intelligence defined as the ability to acknowledge, appreciate, and manage emotions in yourself and in others was identified by study participants as the third aspect of effective resident leadership ( Figure 5) 20,21 .

Empathy
The practice of empathy by healthcare workers is known to increase team effectiveness 22,23 . The participants of this study identified empathy for team members as one of the principal characteristics of resident leadership. One participant stated, "I had great residents, they were great doctors...but the ones that I loved the most were the ones that actually cared about our overall wellbeing, the wellbeing of the team." Participants noted that upper-level residents must qualities also identified in this study 4,25 . However, this study also found emotional intelligence and team ownership equally important. The role of emotional intelligence is often overlooked in studies identifying leadership qualities from the non-resident perspective. Prior studies reported "patient ownership" or "decision ownership" as necessary qualities of resident leaders 25,26 . This study expands upon the concept of ownership by introducing the concept of "team ownership" as a necessary quality of effective resident leadership. Residents demonstrate team ownership by assuming responsibility for not just patient care but also for the wellbeing of team members and all team decisions including any mistakes.
The importance of mentorship has been highlighted in prior studies of resident leadership training programs. In one curriculum, two of the five commitments of resident leadership were 'modeling the way' and 'enabling others to act' 4 . In another study, inspirational motivation was noted to be a crucial component of effective resident leadership 25 . It should be noted that both of these studies defined the characteristics of effective resident leadership from the perspective of individuals other than current residents to design curriculums for residents 4,24 .
Studies from many disciplines (business, management, psychology, and philosophy) describe the importance of ownership and its effects on motivation and behavior [26][27][28]  In the healthcare setting, emotional intelligence has been identified as an important characteristic of effective leadership 16,17 . In a leadership course for internal medicine residents, "leading with emotional intelligence" was identified as a core competency for strong resident leaders and was one of the four main topics discussed over the four-week course 22 . Throughout the focus group discussion of the current study, participants continually spoke about effective resident leaders as individuals who are sensitive to the emotions of their team members, create psychological safety, and appreciate their team members' efforts -all of which are components of emotional intelligence. In prior studies, creating psychological safety was deemed crucial to the efficacy of the medical team 22,29 . It is logical that emotional intelligence is critical to fostering team member wellness, which ultimately impacts patient care as was described by the participants and similarly, identified in a prior study 29 .
While other studies of leadership curriculums for internal medicine residents identified the qualities of effective resident leadership from the perspective of faculty, leadership coaches, and chief residents, they did not include the views of current residents 5,6,22 . Future research endeavors should focus on developing customized leadership curricula committed to developing the characteristics of effective resident leadership as identified by current resident physicians.

Limitations:
The study findings are limited by the small focus group size of five participants from a single center residency program. Additionally, the participants were mostly international medical graduates. The size of the focus group and the background of participants may limit the generalizability of study results to other Internal Medicine residency programs.

Conclusion:
Strong resident leadership is crucial to providing effective residency training and the highest level of patient care. This study identifies from the perspective of current second year internal medicine residents, the principal characteristics of resident leadership: mentorship, communication, team ownership, and emotional intelligence. The identification of these characteristics provides an opportunity to create leadership curricula for residents that focus on developing these specific skillsets. Figure 1 Themes and Subthemes Emotional Intelligence Subthemes

Supplementary Files
This is a list of supplementary les associated with this preprint. Click to download. TheResidentVoiceAppendix.pdf