Being a Supportive Program Coordinator

What?

The goals of this intervention are to:

• Frame the position of the program coordinator as one that supports (rather than corrals or disciplines) the residents
• Provide programs with resources to train supportive coordinators
• Provide concrete examples of supportive activities/gestures that program coordinators can do/make

WHY?

Program coordinators (PCs) are critical to the administration of a residency program. However, there is substantial variability in how PCs view and exercise their role across residency programs, which impacts how supportive residents perceive their PCs to be. The current protocol describes several “best practice” recommendations that programs and PCs may implement to meaningfully improve their residents’ experience.

Efficiency & Resources	PCs are uniquely positioned to identify and alleviate administrative burdens, inefficiencies, or other challenges in the residents’ work environment. By delegating or assumingadministrative tasks, PCs can enable residents to spend more time on their primary goals: patient care and education.
Organizational Culture and Values	Hiring and training coordinators who view their role as supportive rather than disciplinarian reflects the program’s view of residents as capable adults. Additionally, by supporting the professional development of their coordinators and support staff, programs demonstrate that personal accomplishment and meaning in work is important at all levels, establishing a culture of mutual appreciation and goodwill.
Control & Flexibility	Due to the frequent cadence of interaction between PCs and residents, PCs may become a trusted confidant for trainees. They may thus serve as a resource for program leadership to understand resident concerns and may advocate on residents’ behalf. Therefore, PCs may be a safe outlet for resident voice and a means of generating a programmatic response.

Tips for Programs/Program Directors

Step 1. Frame the position of the program coordinator as one that supports the residents

1. Hiring: It should be clear in the job posting and throughout the interview process that resident support is an integral part of the job. You may use/edit any of the following:
   1. Northwestern: “This position acts as a liaison between NMH, Graduate Medical Education, faculty, residents, and the Department. The ideal candidate will be highly motivated, self-directed, and will possess excellent writing, verbal, organizational, and customer service skills.”
2. Onboarding:
   1. The GME office at many institutions provides standard training and central support. You may want to ask your GME office to add/amend their current training if you feel additional support would be helpful.
      1. At UTSW, there are two designated GME training coordinators, who are resources for coordinators if/when any questions arise.
      2. At the Mayo Clinic, the GME office provides an orientation for new coordinators. A designated individual from the GME office comes alongside the new coordinator in their new position to help onboard them.
      3. At OHSU, Gold level coordinators (See Step 2a) mentor newer coordinators
   2. If your GME office does not offer onboarding, consider reaching out to other programs’ coordinators.
   3. Consider additional orientation to surgical residency specifically. Make the work hours and nature of the work as concrete as possible. Talking points:
      1. Qualifications: Surgical residents have completed undergraduate and medical degrees; they are physicians before they start internship.
      2. Work hours: The ACGME duty hour maximum is 80 hours/week, and we schedule them to work for almost all of those. A typical resident wakes up at __am and leaves the hospital at __pm. We typically assign __ pages of reading each week to be done at home. Residents typically get 4 days off in a month. This equals __ number of weekends off. They do not always get to decide when those days are.
      3. Work pace: They are in constant motion between the OR, the ICU, the floors, and the Emergency Room. They often do not have time to eat. They do not have access to personal computers or fax machines.
      4. Other: Residents do not have complete control over where they train. They may be far from loved ones and not have a lot of personal support. They may be sacrificing or delaying major aspects of their personal lives. Residents are heavily involved in the care of critically ill patients and may feel personally responsible for adverse events.

Step 2. Set your program coordinator(s) up for success

1. Make sure you are accessible to them.
   1. You should be in constant communication with them. They should have your cell phone number as well as access to your calendars.
   2. They should be present at most if not all residency-related meetings (e.g., residency leadership meetings, PECs, CCCs, town halls).
   3. If your offices are not physically near or co-located with theirs, consider having touch-down space nearby. At UCSF, the Surgery Education Office created an additional workstation within the office for Dr. Reilly, the Program Director, because her office was across the street.
2. Make sure they are accessible to residents.
   1. They should have time to introduce themselves and their roles at Orientation. See Tips for Coordinators.
   2. If possible, their offices should be physically near or co-located with the space the residents frequent (e.g., resident offices, call rooms, library, lounge).
   3. Make their offices comfortable/attractive to residents. University of Michigan’s Program Manager has a sofa in her office, and she stocks “an exhorbitant amount” of candy (she buys $3000 worth at 50% off the day after Halloween).
   4. If their offices cannot be near resident space, consider building other opportunities for informal interaction into the workweek. See Tips for Coordinators.
3. Make sure they know what their resources are:
   1. Contact information for psychological support for residents (e.g., EAP)
   2. Discretionary funds (e.g., for “cup of coffee” discussions with residents)
4. Redirect, as needed. Sometimes program coordinators come to see their role as supervisory to the residents. This may result in PCs chastising the residents and/or putting their own convenience ahead of the residents. They may also “tattle” on residents (to you). Keep an eye out for these interactions so that you may step in and remind your PCs that you expect them to be supportive. See Tips for Coordinators.
5. Empower them to advocate on behalf of residents by asking for their input when issues/concerns arise.

Step 3. Promote the professional development of your program coordinator(s) and residency support staff

1. Ask your GME office to provide ongoing resources:
   1. At OHSU, the GME office sponsors a professional development series for coordinators. It is a 3-year program with 3 levels (bronze, silver, gold). Bronze and silver levels can be completed simultaneously, so course completion can be expedited to 2 years instead of 3. Gold level addresses leadership and mentorship of other coordinators. Each level is comprised of 10 online modules and leads to a Certificate of Completion. Covered topics include event planning, resident remediation, interview season, etc. There is an assessment at the end of the series, consisting of essay prompts. Those who complete all 3 levels receive a $1000 incentive.
   2. UCLA, UTSW, and the Mayo Clinic all have regular (i.e., monthly or every other month) GME-sponsored meetings for PCs in all disciplines. These coordinator forums promote sharing of ideas and provide a network of institution-wide coordinator support. Mayo Clinic offers brown bag sessions to their program coordinators on resident well-being.
2. Fund/reimburse membership in the Association of Residency Administrators in Surgery (ARAS), a national association of surgery residency coordinators (supported by the Association of Program Directors in Surgery [APDS]) and previously known as the Association of Residency Coordinators in Surgery (ARCS). Membership costs $225 annually. Here is the FAQ page.
   1. Participating in ARAS may afford an even higher-level community of support for PCs. PCs can request access to the private Facebook Group to share experiences and learn from program administrators of surgery residency programs across the country.
3. Fund/reimburse and provide time for program coordinators to attend conferences. These conferences provide a mechanism for PCs to learn from PCs at other programs, such as how program surveys are executed, and how other PCs interact with their residents.
   1. At UTSW, the PCs go to the ACGME conference and the APDS/ARCS conference each year. Financial resources are available for coordinators to go to other conferences if they have a specific interest.
   2. The SECOND Trial will host a coordinator-specific session at the spring 2021 SECOND Trial conference.

Tips for Coordinators

Step 1. Introduce yourself

1. Orientation should include podium time for you to introduce yourselves and explicitly state that your office is available to support the residents as much as you can.
2. You should make a point to interact socially with each resident face-to-face at Orientation.
3. Residents will be in and out of your offices for a variety of reasons (e.g., paperwork). Use these. opportunities to try to get to know them. As Rachelle Bresnahan, the UCSF Surgical Education Office Administrative Director says, “I always ask them how they’re doing, who their families are, where they come from, where they grew up, what their interests are – just to try and get to know them as much as I can.”
4. Try to think of yourself as a “big sister, den mom hybrid” or a “friend-peer.” Be empathetic. See Step 3 for advice about tone.
5. It can be a fine line to walk, particularly if you are around the same age as the residents. You need to be, as Rachelle Bresnahan at UCSF says, “a friend with boundaries.”

Step 2. Create opportunities for ongoing face-to-face interactions with residents

If your offices are not near resident space, you need another way to informally interact with them that doesn’t require them to initiate outreach.

1. Management By Wandering Around (MBWA) leadership principle[1,2] encourages regular physical presence within a team’s work environments and presents an informal opportunity to talk with team members, ask questions, actively listen to ideas, observe work processes, collect information, and resolve problems. Suggestions:
   1. Attend resident conferences. At UTSW, the PC noted that residents didn’t often reach out to her with concerns, but that whenever she casually ran into residents, they would often share issues that she was able to help address. She started attending resident conferences under the guise of manually taking attendance and found that residents often shared concerns with her as she was sitting in the back of the conference room. To maximize her time during the didactic portions of conference each week, she brings a laptop to accomplish other work.
   2. Stock their common space (e.g., food, paper, toner). At UTSW, the PC delivers snacks to the surgery work rooms at each of their hospitals once per week. She texts them when she is en route to each site. This has decreased the activation barrier for residents to contact her; they feel more comfortable reaching out about over small issues over text (e.g.,refilling the ink and printer paper in the call room).
2. Keep track of any issues or concerns that you find. You may want to ask other residents to see if this is a common concern (protecting the confidentiality of the first resident, of course). Address them with the program leadership at their weekly meeting (again, protecting the confidentiality of the residents). The UTSW PC noted that residents many issues brought to her attention were “off the record,” since residents didn’t want to be known for complaining and therefore were not inclined to send an email (i.e., leave a paper trail) with their concerns.
3. As the PC, you may have a totally different and appreciated perspective from program leadership, and your input could be invaluable. Strategize together with your PD regarding potential solutions.

Step 3. Make the administrative tasks less painful

Residents are incredibly busy and have little downtime.

1. Complete as much of their paperwork as you can (e.g., everything except the signature).
2. Give them ample notice to complete any remaining paperwork. If possible, use Orientation (or another session at which everyone is present at the beginning of the year) to update all paperwork for the entire academic year. At Northwestern, VA paperwork is time-sensitive, so the coordinator puts together all the paperwork at the beginning of the year and leaves the date blank until the resident is ready to rotate there.
3. Do not send emails, texts, or pages with chastising or threatening tones.
   1. Reminders may be in order, but avoid communicating your own annoyance. Remember that residents are highly educated, highly accomplished adults; they are physicians before they start intern year. Administrative tasks are not (and should not be) at the top of their priority lists. As the OHSU PC says, “At the end of the day…I just realize that my job – I’m just pushing emails all day and schedules, and I’m not dealing with the things that they deal with. So, just being understanding of that – it’s like, if you don’t do your duty hours, I’ll give you a slight nudge in person, but I’m not going to hound you constantly about it…Just playing to that – where to let some things go.”
   2. If such a more disciplinary communication needs to be sent, your PD should do it. As the OHSU PC says, “I definitely let Dr. Brasel handle, and Erin [Education Manager] handle more of the hard hitting stuff.”
4. Avoid complaining about the residents to your PD. Attempts to align your PD’s sympathies with you against his/her residents will create resentments and divisions in the program. Remember, you, the residents, and the PD are all on the same team.

Step 4. Go the extra mile to support residents

1. Deep data dives: At UCLA, to double-check integrity of duty hour reporting, the PC runs comparison reports between the hours reported by general surgery residents and non-general surgery residents on the same service (e.g. orthopedics, ENT, radiology, etc.), which are in turn reviewed by the PD, APD, vice chair of education, and chief residents. Because they suspect that general surgery residents are incentivized to under-report, they investigate any discrepancies (via the senior residents on the service and the administrative chief residents). If the problem seems to be faculty-driven, the PD will engage with the service.
2. Notary services: At UTSW, the residents were having a hard time getting their USMLE applications notarized, so the PC became a notary. This service has also been helpful when residents are buying houses or getting marriage licenses. Since residents know that they will see the PC each week at their conferences and when she delivers snacks (see above), they no longer need to depart from their typical work routines to get documents notarized. To find out how to become a notary in your community, please visit: https://www.nationalnotary.org/. Ask your program to cover the associated costs.
3. Administratively support resident wellness activities: assume any logistical responsibilities associated with resident wellness activities. At Northwestern, residents visit an EAP provided therapist twice a year, which is scheduled by the coordinators. During COVID, social events have been transitioned to class dinners (i.e., small groups), held within the hospital at social distance; coordinators book the rooms and order the food. Coordinators attend residency wellness committee meetings to learn about upcoming initiatives and to suggest their own ideas.
4. Consider the following simple, inexpensive, and meaningful interventions created by PCs and support staff based on their unique perspective of the resident experience:
   1. Quick Wins: Small Positive Gestures to Show Appreciation for Residents
   2. Baby Box

Step 5. How to support struggling residents

Many of these tips are from our Peer Support intervention; consider formal training if in place at your program.

1. Surveillance: look for any behavior or mood changes.
2. Ask the question. Outreach is important because surgical culture tends to promote toughness, and residents may be afraid of asking for help and looking weak. “How are you doing?” “What’s going on?” “You seem off. Is everything ok?” “Is anything bothering you?” Allow for silence.
   1. You may want to approach them outside of the office or workplace. Rachelle Bresnahan at UCSF sometimes meets residents for coffee or takes them to lunch.
3. Remember that program directors are in an evaluative role over the residents, and residents may be particularly averse to sharing their struggles with them. Remind the resident that you will not betray their confidence. “I will not share this with the program directors.”
4. Listen. Do not interrupt. Do not judge. Do not rush to fix. As Rachelle Bresnahan at UCSF says, “I try to empathize with them. I try to put myself in their situation…Sometimes it’s not stuff that needs to be told the program directors – it’s just that they needed somebody to tell.”
5. Share your experiences, if you think that will help normalize their feelings, but be careful not to shift the focus of the conversation away from them. As Rachelle Bresnahan at UCSF says, “I share some of my life experiences with them so they feel comfortable…I just offer my life experiences so that they can relate. That’s my truth. I can say what I think or give words of encouragement. Never be dishonest. Then refer them back to the idea, ‘I think you should really get some help.’”
6. Bump it up, if needed.
   1. You are probably not trained as a therapist. If you feel that the resident needs further help, give them a list of resources available to them. This list could include departmental resources (e.g., a Peer Supporter), institutional resources (e.g., EAP), or local resources (e.g., a counseling group that takes the residents’ insurance). Remind them that all of these resources are confidential, and that the department does not get any feedback about them; this is a common resident fear.
   2. If you think the program director could help, encourage the resident to talk to their program director. “I think Dr. [PD] would be really supportive; s/he won’t be judgmental or upset. I think s/he will be your best advocate and you should talk to him/her.” As Rachelle Bresnahan at UCSF explains, if the resident goes to your PD him/herself, “they feel like they’re in charge of their decision making, rather than [being told on].”
   3. If you are afraid the resident might harm him/herself or others, then you must get additional help. Again, give the resident the opportunity to talk to the PD him/herself. Tell the resident: “Ok, I’m going to have to share this with Dr. [PD] – or you can share it with him/her.” “We’ll do this together.”
   4. Give your PD a heads-up so that they can be mentally prepared, but do not betray confidentiality: “I talked to [resident], and s/he should be coming to you.”
7. Follow-up with the resident by text or in person. “How are you doing? I haven’t talked to you in a few weeks? Are you feeling better?” “Did you talk to [PD]?” “Did you talk to [EAP]?” “You really need to. We talked about this. I am concerned about you.” As Rachelle Bresnhan at UCSF says, “Keeping the dialogue going and just being supportive…is key and sometimes just what they need. Then they go and take care of it however else they need to.”

Helpful Resources

Coaches/Successful Implementations

University of California, Los Angeles

Coach: Chi Quach, Program Coordinator

University of Texas, Southwestern

Coach: Lisa Bailey, Supervisor of Education Programs

Oregon Health and Sciences University

Coach: Erin Anderson, Education Manager

University of California, San Francisco

Coach: Rachelle Bresnahan, Administrative Director

References

1. Mohan DR, Kumar SS, Subrahmanyam G. Management by Walking Around: an effective tool for day-to-day operations of hospital. IUP Journal of Operations Management. 2013 Feb 1;12(1):58.
2. Management by Wandering Around (MBWA): Keeping Your Finger on the Pulse. Mindtools.com. 2020. Available from: https://www.mindtools.com/pages/article/newTMM_72.htm