Program Director’s Corner – January 2020
A sunsetting program director’s reflections on program leadership
Christopher McCartney, MD
Program Director, Endocrine Fellowship Program
University of Virginia
I’ve been a program director since 2011, and I’ve valued it a sacred privilege. In early 2019, however, I decided to step down from the program director position effective July 1, 2020. Since this decision, I’ve reflected a fair bit on my tenure as a program director—the goals I did and didn’t achieve, the struggles I encountered, and the lessons I learned. In this Program Director’s Corner, I’ll share my reflections on two particular struggles and what they taught me about program leadership in general.
A goal achieved, but not universally lauded
Our fellowship program was strong in 2011, but I had some changes in mind. My sense was that the distribution of mandatory clinics wasn’t ideal, so one of my first goals was to reorganize these assignments. For example, fellows spent a lot of time in a very prominent, highly-subspecialized clinic. However, some fellows had criticized the amount of time spent in this clinic. My sense was that an excellent training experience did not mandate so much time in this clinic, and I felt that the amount of time fellows spent in this clinic had important opportunity costs. I therefore worked with the Program Evaluation Committee to establish a putatively more ideal mix of required rotations (clinical exposure). However, a small handful of more-senior faculty members—the most vocal of whom worked in the highly-specialized clinic described above—criticized the new rotation structure, at least partly based on a different conception of what’s best for the fellows.
A note about me: I often find such criticism unnerving. I’m a card-carrying introvert, I sometimes doubt myself, and my natural inclination is to avoid confrontation. Moreover, my division was (is) rather hierarchical, I was a relatively early-career faculty member at the time, and my more-senior faculty colleagues had all trained me as a fellow. In this context, I second-guessed my leadership decision. However, several considerations provided me with the courage to stand my ground against these vocal critics. First, the pros and cons of competing rotation-assignment models had been very carefully considered, and I was convinced that the rationale for the new rotation structure was sound. Secondly, the plan had been vetted by, and fully endorsed by, the Program Evaluation Committee. Thirdly, and I think most importantly, the program director is ultimately responsible for furthering the fellows’ bests interests: I remained convinced that the new plan would better serve the fellows, and I knew I had to stay true to that conviction.
A goal unachieved and feelings of failure
For at least 20 years my division has completely depended on fellows to cover our general endocrine consult service. Approximately half-way through my tenure as program director, the lack of reliable external funding for research training led to a divisional incentive to reduce the number of fellows. In this context, it became clear that our total reliance on fellow consult coverage was a potential problem—if any fellow were to require a prolonged absence, we would be at risk for a substantial consult-coverage shortfall. These fears were first realized in the 2017-2018 academic year: one of our fellows elected to stop fellowship after one year, and another fellow would need maternity leave, rendering an 18-week shortfall in fellow consult coverage. If I were to require the remaining five fellows to fully cover the shortfall, I would be asking them to do substantially more consult time than I had judged necessary for their training. And while additional time on the consult service could provide some additional educational benefit, the work involved is somewhat arduous, and I wasn’t convinced that the incremental educational yield justified the extra work. Another potential coverage gap arose in 2019: given a programmatic transition in the Endocrine University program, it was possible that all of our fellows would be allowed to attend Endocrine University in February 2020. Thus, I didn’t schedule any fellow to be on consults that particular week.
In both cases, I asked divisional leadership to engage the faculty in a discussion about how faculty could cover the fellow coverage shortfalls. Such discussions never happened, though, in part related to divisional leadership’s (valid) concern about how to assign faculty coverage in an equitable way. In addition to this reluctance on the part of divisional leadership, the fellows and I were concerned that, because of the long-standing expectations of faculty members, requiring faculty members to cover consults without fellow help could generate fellow-directed resentment on the part of some faculty members. In the end, we addressed both of the above situations by allowing fellows to cover consults as a moonlighting opportunity: this was a fully-voluntary activity, and the division provided generous supplemental pay for the fellows’ efforts. This arrangement was a clear concession on my part, and I can’t quite shake the feeling that I had somehow failed in my duty as a program director. Perhaps I shouldn’t have given any ground? Perhaps I shouldn’t have relented to the prevailing divisional expectation that fellows will always cover consults fully? I console myself with the thought that the moonlighting arrangement may have been the best I could have done at the time. I also believed that the arrangement represented a step in the right direction, and my hope is that it will pave the way for future improvements in this regard.
We program directors are leaders, and being a leader can be challenging. I believe that the above-described challenges highlight some important concepts, which I summarize below.
- Fellowship programs function within endocrine divisions, and fellowship training requires the educational efforts of individual faculty members. However, the fellows’ best interests may at times conflict with the most-immediate interests of individual faculty members or even divisional units as a whole. Thus, we as program directors can be caught in the middle—between the needs/desires of our primary constituency (fellows) and the needs/desires of our colleagues and/or supervisors.
- Wisdom includes knowing how hard to push (sometimes, but not always, you have to be a persistent gadfly), and it includes knowing how hard to push back (sometimes, but not always, you have to be stubborn in the face of external pressure). At the same time, we should allow room for, and do our best to learn from, good-faith disagreements about what is in the best interests of fellows.
- It is important to have an explicit—and ideally a very-compelling—rationale for any program-related decision that could conflict with the most-immediate interests of faculty colleagues and/or the division as a whole. Moreover, the importance of building general consensus (e.g., via the Program Evaluation Committee) cannot be overemphasized. At the end of the day, a program director’s primary responsibility is to advance what she or he believes is in the fellows’ best interests, even when it requires respectfully-adversarial interactions with those higher in the divisional, or perhaps even institutional, hierarchy.
 My rationale was two-fold. Most importantly, my program directorship had transitioned from a building mode to a maintenance mode; the program would benefit from “new blood”—someone who would bring new ideas and a renewed energy. Secondly, my division had several more-junior faculty members who could be outstanding fellowship program directors, and at some point it’s important to make way for the next generation of leaders.
 This clinic indeed provided an excellent educational experience. The clinic also generated substantial resources and brought substantial prestige to the University; in my admittedly cynical view, the latter considerations had influenced the amount of time fellows spent in this clinic.
 We developed a rotation plan we believed would optimally achieve two primary goals: (1) a balanced mix of exposure to the different areas of endocrinology, and (2) a diverse exposure to our different faculty members within those different areas of endocrinology.
 I acknowledge here that there will be certain times when your convictions should change on the basis of alternate views that you hadn’t adequately considered.
 The fellows have appropriate faculty oversight, of course, but consult fellows do the bulk of the work.
 The most common critique I’ve received about my posture goes something like this: the fellows aren’t overworked, and all clinical activity promises an educational benefit. But my thoughts on this issue tend to be dominated by the incentives at play: instead of assigning the work to meet educational requirements, we would have asked the fellows to do the work primarily—if not exclusively—to meet divisional work-capacity needs. I want to note here that our fellows are not reluctant to work. However, they want their work to be tangibly and legitimately justified vis-à-vis their education. I believe their desires in this regard are fully justified.
 For example, while the assignments could be determined by lottery, some of our faculty could not adequately function on consults (without fellow help) given ignorance of the mechanics of modern inpatient consultation; as a result, the junior faculty would be unfairly targeted for consult coverage.
 I suspect that the fellows still felt some internal pressure to volunteer.
 This may even include the program director’s immediate boss—the division chief/director.