The outgoing chief residents graduate. The new ones step forward. And in most programs, that is roughly where the formal attention ends.

Chiefs are expected to lead. To manage schedules, mediate conflict, represent the resident voice, and hold the space between program leadership and the resident body. They are the most visible residents in the program and often the least supported ones.

The question most programs don’t ask clearly enough is this: who is usually looking out for them?

What the Role Actually Asks

The chief resident role is one of the more complicated positions in graduate medical education. It asks someone to step into a leadership function, often with minimal formal preparation and a title that implies authority they may not fully know how to use yet. For some, the chief year comes after completing residency. For others, it falls within their training, meaning they are simultaneously navigating their senior year, with all the clinical and professional demands that carries, while also being asked to lead their peers.

In both cases, the transition into the role rarely comes with the kind of deliberate onboarding and mentorship it deserves.

In practice, chiefs end up absorbing a wide range of responsibilities that were never explicitly defined. Scheduling. Conflict mediation. Communicating program expectations to a peer group that still sees them as peers. Fielding complaints. Serving as a buffer between residents and program leadership in ways that can put them in an impossible position.

And alongside all of that, they are still supposed to be learning. Still accruing the clinical and professional competencies that define the end of training. Still preparing for whatever comes next.

The tension between those two things, the administrative demands of the role and the developmental needs of the person in it, is where most chief residents experiences suffer.

The Administrative Trap

One of the most common patters I have watched play out is what happens when a chief resident’s time and energy get consumed almost entirely by administrative tasks and interpersonal management.

Schedules need to be built. Residents have conflicts that someone needs to address. Emails need to go out. Logistics need to be managed. And the chief, because they are available and capable and because it feels like their job, does all of it.

What doesn’t happen is the other half of what the role should be. The curriculum design work. The preceptor experience. The faculty development opportunities. The ACGME competency completion. the conversations about what this year is supposed to be building toward and whether it is.

By the time June arrives, many chiefs have been highly functional administrators and underdeveloped physicians. They managed the program beautifully. Nobody asked whether the program was managing them.

The Conflict Mediation Problem

This deserves its own mention because it comes up constantly.

Chiefs are routinely asked to manage interpersonal conflicts within the resident body. And while some of that is appropriate, there is a version of it that crosses a line. When a chief is placed in the middle of a dispute between two residents, or between a resident and a faculty member, or between a resident and the institution, without clear guidance, formal authority, or backup support from program leadership, the role becomes something it was never designed to be.

Chiefs are not HR. They are not mediators. They are not the person responsible for managing situation that require program director or GME involvement. When they are asked to handle those situations informally, they absorb the emotional and relational cost of problems that are not theirs to solve, often without any formal acknowledgement that this is happening.

The program director who sees the pattern and steps in to clarify what the chief’s role is and is not in conflict situations is doing something important. Not just for the chief, but for the entire residency culture.

What Good Support Actually Looks Like

Supporting a chief resident well is not complicated. It is just rarely done with intention.

At the program level, it means the program director is meeting with their chief consistently, not just to troubleshoot problems but to ask about the chief’s development. What are they learning this year? What clinical experiences are they getting? What competencies still need attention? Are they on track for the next role, and is anyone helping them think about what that role is?

It means ensuring the chief is still precepting, still participating in educational activities, still being pulled into curriculum conversations and faculty development opportunities. Not just when they have time, but as a deliberate part of how the year is designed for them.

It means being honest about what the chief should and should not be asked to handle. The program directors who offload difficult interpersonal situations to a chief because it is convenient is not mentoring a leader. They are protecting themselves at a resident’s expense.

At the institutional level, the DIO can make a meaningful difference by ensuring chiefs have a seat in some leadership conversations. Not every meeting, not every decision. But enough visibility into how the institution functions that they understand what GME leadership actually looks like at a level above the program. That exposure matters for chiefs who are heading into academic medicine. It also matters for their sense that the institution sees them as more than a scheduling resource.

Preparing Them for What Comes Next

A chief resident who wants to stay in academic medicine needs more than a strong clinical year. They need to know how to design curriculum. How to give formal feedback. How to precept a learner who is struggling. How to navigate an institution. How to think about faculty developments as something they participate in, not something that happens to other people.

Most programs assume that if a resident is good enough to be a chief, they are good enough to figure out the rest. That assumption is not always wrong. But it leaves a lot of development to chance in a year that should be one of the intentional of someone’s training.

The question to ask at the start of the chief year is not just what do we need from you. It is what do you need from us? What does this year need to produce for you to be ready for the next chapter? And then, genuinely, build a plan around the answer.

If a chief is heading into private practice, the developmental priorities look different than if they are staying in academic medicine. If they are finishing their chief year before completing residency, the clinical and competency picture looks different than if they are already board eligible. The plan should reflect the person, not just the role.

Chief residents give a lot to their programs. They hold things together during the hardest transitions of the academic year. They carry the resident voice into rooms where it might not otherwise be heard. They do unglamorous work that makes the program function, often quietly and without recognition.

What they deserve in return is a program that takes their development as seriously as their utlity.

Not just a title and a set of tasks. A year that actually prepares them for what comes next.

The new chiefs are officially on their own now. The question worth asking is whether anyone has asked them yet what they actually need from this year.

And whether the answer is shaping how the program shows up for them.

Every summer, in orientation rooms across the country, a ritual takes place.

New residents and fellows settle into chairs, name tags fresh, white coats pressed. Someone hands out an agenda. And at some point, usually early, the ice breaker begins.

Name. Fun fact. What is you goal for this year? Or some version of it. What do you hope to accomplish? What doe success look like for you at the end of this? What kind of physician do you want to become?

The answers are almost always some version of the same thing. To grow. To learn as much as I can. To become a better doctor. To be present for my patients. To make i through. Sometimes a laugh, sometimes a quiet sincerity, sometimes both at once.

And almost every one of those answers is true in the moment it is given.

What nobody says out loud in that circle is what they year will actually ask of them.

The Gap Between the Goal and the Year

The goal stated in the ice breaker is usually about becoming. The year that follows is almost always about surviving, adapting, and discovering things about yourself that no orientation question could have surfaced.

There will be shifts that go wrong and rotations that are harder than expected. There will be feedback that stings and praise that arrives too late to matter as much as it should have. There will be patients who stay with you long after the chart is closed and moments that make you question whether you have what this requires. There will be nights that make July feel like it happened to a different person.

And then somewhere in the middle of all of that, usually when nobody is paying attention, something shifts. The notes start coming a little faster. The presentations feel a little more natural. The uncertainty that felt paralyzing in the beginning starts to feel like something closer to judgement. The becoming that was named so simply in the ice breaker is actually happening, just not in the way anyone pictured when they said it out loud in July.

That is how it almost always goes. With bumps and bruises along the way. With lessons that costs something before they teach something. With growth that is rarely linear and almost never comfortable.

What Purpose Actually Looks Like in Practice

There is something worth honoring in the ice breaker question, even when the answers feel a little rehearsed.

Because having a stated purpose, even an imperfect one, even one that will be tested and revised and sometimes abandoned before the year is out, is better than arriving without one. The resident who says “I want to be present for my patients” may not fully understand what that means yet. But they will, by June have a much clearer sense of what presence costs, what is requires, and when it is hardest to sustain.

The goal is not a prediction. It is an orientation. A direction rather than a destination. And the year has a way of taking that direction and putting it through every kid of pressure test until something real and durable remains on the other side.

Most people, by the time they get to the end of the year, find that the goal they stated in July was right in spirit even when the specifics needed adjusting. They wanted to grow, and the grew, just not in the ways they expected. They wanted to learn, and they learned, including things they never anticipated having to learn. They wanted to become better physicians, and they did, usually be discovering exactly what it costs to be one.

A Note on Expectations

If there is one thing I have watched residents and fellows navigate, year after year, it is the collision between expectation and reality.

The expectations that residency will be hard, which everyone is told, and the reality of what hard actually feels like, which nothing quite prepares you for. The expectation that support will be there when you need it, and the experience of having to ask for it in ways that don’t feel natural. The expectation that the goal stated in July will remain intact through December, and the discovery that sone goals need to be updated, not abandoned, but made more honest by what the year has already required.

Managing expectations is not about lowering them. It is about holding them with enough flexibility to let the year teach you something you couldn’t have known in the ice breaker circle. The residents and fellows who move through training most successfully are rarely the ones who arrived with the clearest picture of what they wanted. They are the ones who stayed curious when their picture needed revising.

To The Class Beginning July 1st

If you are walking into orientation this week, here is what I would offer alongside whatever goal you share in the circle.

Hold the goal lightly enough to let the year reshape it, and firmly enough to return to it when the year gets hard. Know that the bumps and bruises are not signs that something has gone wrong. They are signs that something real is happening. Let yourself be changed by what this year asks of you, because the change is the point.

And when someone asks you next June what you accomplished this year, notice how different the answer is from the one you gave in July. That difference is the evidence of everything the year actually taught you.

To the Class Completing the Year Today

June 30th is its own particular kind of threshold.

The goal you named at the beginning of residency is behind you now. The years that followed it, with everything it asked and everything it gave, is what you are carrying forward.

Whatever you expected, whatever you hoped for, whatever surprised you, challenged you, or change you along the way, you made it through. That matters more than whether the year looked anything like what you described in July.

Thank you for what you brought to it. And to the patients who trusted you with something important while you were still figuring it out, that trust was not misplaced.

Closing Reflection

Purpose and expectation are not the same thing.

Purpose is the direction you set when you begin. Expectation is the picture you carry of what the path will look like. Residency has a way of honoring the first and humbling the second, often in the same week.

The ice breaker question is worth asking, not because the answer predicts the year but but because it asks the person standing at the beginning to name something they care about, before they year has had a chance to complicate the answer.

What they say in that moment is who they hope to become.

What June 30th reveals is who they actually are.

Subscribe now

Every spring, while residency programs are deep in graduation planning, final evaluations, and orientation prep, a quieter and more urgent process is unfolding alongside it.

International medical graduates preparing to start residency on a J-1 visa are racing against a clock that very few people outside GME ever see.

Every year, without fail, a portion of these applications fall behind schedule. Some years it is worse than others. But the pattern itself is almost a constant in graduate medical education: a predictable, recurring bottleneck that everyone in this field has come to expect, even though expecting it does nothing to reduce the anxiety it creates for the people living through it.

What the Role of TPL Actually Involves

For programs with international medical graduates, the Training Program Liaison role exists to support residents and fellows through this process. Tracking visa status. Encouraging early action on documentation. Follow up, again and again, on the steps that are within everyone’s control.

And that is really the heart of it. Most J-1 delays are not the result of some single dramatic failure. They are the accumulation of small things, a document not uploaded in time by the program, the TPL, or the applicant, and sometimes something further outside anyone’s direct control: the home country letter.

For many applicants, securing the statement of need or home country letter required for their visa means navigating a foreign government office, sometimes one with its own backlog, it’s own bureaucracy, and it’s own timeline that has nothing to do with anyone’s residency start date. A resident can do everything right on their end, submit every form early, follow every instruction, and still find themselves waiting on a document that is sitting on someone else’s desk in another country. That piece of the process is real, and its genuinely not something a program, a TPL, or even the most diligent applicant can force to move faster.

So it is rarely just one party’s delay. It is often a combination, a form that stat too long on this end, a letter that is taking longer than expected on the other end, and a calendar that does not care which one is the cause.

I have done this work, and the truth of it is something most people outside GME never see. You encourage residents to start early. You remind them in December, while they are home for the holidays, that the paperwork for the following year needs attention. You remind the newly matched residents the moment they match in March that timing matters enormously and that waiting has consequences they may not fully understand yet. You do everything within your power to create urgency without creating panic.

An still, every year, some applications fall behind. Not because anyone failed dramatically, but because several parties all have to move in sync, here and abroad, and it only takes one piece moving a little slowly to put the whole timeline at risk. The difference between a smooth visa season and a stressful one often comes down to a few weeks of lead time that everyone involved is racing to protect.

The Anxiety Runs in Both Direction

What gets lost in conversations about visa timelines is how much anxiety exists on both sides of this process, simultaneously for the entire spring.

The incoming residents is living with genuine uncertainty about their own life. Will my paperwork clear in time? Will my home country letter arrive before the deadline? Will I be able to start on time? What happens to my career, my housing, my family, if this does not resolve before July? For someone who has been spent years training for this moment, the idea that a delayed document, whether it is theirs to control or not, could derail it is not an abstract bureaucratic concern. It is deeply personal.

And the institution feel it too, in a different but very real way. Every program with international medical graduates is watching the same calendar, knowing that a delayed start date does not happen in isolation. It happens inside a system that has already finalized rotation schedules, clinic assignments, and call schedules for the entire class. July 1st is not a flexible date. It is the day an entire institution recalibrates at once: outgoing residents step into new roles, new residents and fellows arrive, supervision structures shift, and every program absorbs a wave of transition simultaneously.

A single resident who cannot start on time does not just affect that resident. It affects the rotation they were assigned to, the attending who was expecting a full team, the fellow residents who many need to absorb additional coverage, and the patients on that service. The ripple happens during a period when the entire institution is already managing its own complexity, residents being promoted, new faces arriving, schedules shifting everywhere at once.

It is worth briefly naming that this anxiety is not limited to incoming residents. Continuing residents and fellows already in the country on J-1 status can also experience delays, often tied to renewal documentation or status updates that hit the same kind of bottleneck. The stakes look different for someone already established in a program, but the underlying pressure, waiting on a process that depends on multiple parties and sometimes a foreign government office moving on time, is the same.

What This Reveals About the System

This is not, at its core, a story about any single resident or any single program. Its a story about how predictable this bottleneck has become, and how little margin most programs build in to prevent it.

Programs do what they can. TPLs encourage early action. Institutions communicate clearly and often with the residents navigating this. But the timeline only works if every party involved treats the deadlines with the urgency they deserve, starting in December for returning residents and immediately upon match in March for incoming ones, and even then, a piece of the process depends on office and timelines an ocean away. When any one piece clips, whether here or abroad, the entire process tightens, and the anxiety compounds for everyone watching the calendar.

Knowing that this happens every year does not make it easier. If anything it raises a harder question: if this bottleneck is this predictable, what would it take to actually build a process resilient enough to absorb it, rather than simply bracing for it annually.

Closing Reflection

Every July 1st in graduate medical education carries its own particular weight. New residents arrive. Outgoing ones step into their next chapter. Entire institutions recalibrate at once.

For international medical graduates and the programs supporting them, that weight carries an additional layer every single year, a visa process that depends on documentation, timing, and coordination across people and institutions who do not always move at the same pace, some of them entirely outside anyone’s reach.

What I have learned doing this work is that you do what is within your control. You encourage early. You follow up consistently. You build the relationships and the reminders that give the process its best chance of moving smoothly. And then you sit with the anxiety alongside the people living it, because watching the calendar with them, even for the parts neither of you can control, is also part of the job.

The residents arriving this July deserve a process that moves as urgently as they do.

Most years, it gets there. The anxiety along the way is real either way.

Every July 1st, a new academic year begins in graduate medical education.

New residents arrive. Schedules get distributed. Orientation happens. And then in most programs, something quieter and more consequential takes place: everyone figures it out as they go.

Rounds happen when they happen.
Discharges happen when they happen.
Attendings show up with varying degrees of clarity about what their role in the educational enterprise actually requires of them. Residents learn by absorption, by proximity, by trial and error in environments that were never explicitly designed for learning.

This not a failure of commitment. Most people in academic medicine care deeply about education. It is a failure of structure. And it is one of the most persistent and least discussed problems in graduate medical education.

What the Goals and Objectives Actually Say

Every accredited residency program has goals and objectives. ACGME requires them. They live in program documents, in New Innovations, in the materials handed to residents at the start of each rotation.

Most of them describe what residents are expected to learn. Some include a list of recommended readings or core references. A few gesture toward the competencies that will be assessed at the end of the rotation.

Almost none of them describe what the rotation will actually look like.

Not the anticipated schedule. Not how many clinic sessions versus inpatient sessions versus teaching sessions a resident should expect. Not who they will work with or what those attendings are specifically responsible for teaching. Not what a typical day looks like, what time rounds start, what the expectation is around discharges, or how the educational experience is structured within the reality of patient care demands.

The result is a document that describes outcomes without describing the environment designed to produce them. And an environment without explicit structure is not a learning environment. It is a service environment with educational language attached to it.

The Service vs. Education Imbalance

This is the tension that academic medicine has never fully resolved and rarely discusses honestly: residency programs exist simultaneously as educational programs and as workforce solutions. Residents are learners and they are also, in very practical terms, essential to the functioning of the clinical service.

That dual role is not inherently problematic. Learning happens in the context of real patient care, and that is as it should be. The problem arises when the service demands consistently crowd out the educational design. When the rotation exists primarily to staff the floor and the educational goals exist primarily to satisfy accreditation requirements.

When that happens, a few things follow predictably.

Accountability becomes diffuse. If no one has clearly defined what the educational experience is supposed to look like, no one can be held responsible when it falls short. The resident who isn’t learning efficient rounding practices has no framework to measure against. The attending who isn’t providing structured teaching has never been told explicitly that structured teaching is part of their role on this rotation. The program director who receives end-of rotation evaluations full of vague feedback has no baseline to interrogate them against.

Expectations become implicit rather than explicit. Rounds happen at 8am in some programs and 10am in others, not because of any educational rationale but because that is what has always happened. Discharges happen whenever they happen because no one ever built a structure around when they should happen. Residents figure out the unwritten rules by watching, by asking quietly, by making mistakes in environments where the rules were never written down.

And the free-for-all becomes normalized. After enough years, the absence of structure stops feeling like a gap and starts feeling like the culture. This is just how it works here. Everyone adapted. No one questions it.

The Ripple Effect Nobody Talks About

The impact of unstructured educational environments does not stay inside the educational relationship between attending and resident. It moved outward, into every corner of the hospital, and it touches everyone.

Nursing staff absorb the uncertainty first. When rounds happen at unpredictable times, when discharge orders arrive without warning or not at all, when the team composition changes without communication, it is the nurses who field the questions, manage the gaps, and hold the clinical environment together while the educational structure figures itself out. That is not their job. But in programs without explicit structure, it becomes their reality.

Patients feel it too. The patient waiting for a discharge that was supposed to happen at noon but hasn’t been written because the attending hasn’t rounded yet, or because the resident wasn’t sure whether that was their responsibility, or because no one ever built a structure around when discharges should happen. That patient is not a bystander to an educational problem; they are experiencing it directly.

And the institution absorbs it systemically. Length of stay metrics. Throughput data. Patient satisfaction scores. Nursing retention. These are not separate from the educational structure of residency programs. They are downstream consequences of it. A hospital where the educational enterprise runs without explicit structure is a hospital where the clinical enterprise runs with predictable inefficiency, not because anyone is negligent, but because the systems that should create accountability and clarity were never built.

This is the argument that most discussions of the service versus education balance never fully make: the cost of educational disorganization is not borne only by residents and programs. It is distributed across the entire institution, and some of the people bearing it most directly have the least ability to name what is causing it.

What Structured Educational Design Actually Looks Like

The programs that have genuinely resolved this tension share something in common: they made the implicit explicit. They took the time to design the educational experience as deliberately as they designed the clinical service, and they documented that design in ways that create accountability at every level.

At the rotation level this means goals and objectives that go beyond learning outcomes to describe the actual structure of the educational experience. What does a typical week look like? How many clinic sessions, inpatient days, teaching conferences, and procedural opportunities should a resident except? Who is the primary attending for each component and what is the attending’s specific educational responsibility? What time do rounds start and why? What is the expectation around discharge planning and how does that connect to the educational goals of the rotation?

There are not bureaucratic questions. They are the foundational questions that determine whether a rotation produces the learning it was designed to produce or simply produces clinical work with education as a byproduct.

At the attending level this means faculty who understand their role in explicit terms. How many sessions per week does this attending have dedicated to resident teaching? What does their productivity expectation look like and how does the program account for the time investment that genuine teaching requires? Has anyone sat with them and discussed what effective supervision and feedback look like in the context of this rotation?

Faculty development in most programs treats teaching skill as something attendings either have or don’t have. The more foundational question is whether attendings have been given a clear picture of what their educational responsibilities are and what the program expects them to deliver.

At the program level this means someone is looking at the schedule every year, not just distributing last year’s version with updated names. How has the clinical volume changed? How has the resident complement changed? Are the educational goals still aligned with what the rotation actually produces? When did we last ask residents whether the structure we designed is the structure they are experiencing?

The Follow-Through Problem

Here is the part of the conversation that most articles leave out.

Building explicit educational structure is not a one-time exercise. It is an ongoing commitment that requires someone to follow up and follow through, consistently and over time. And progress is rarely immediate. The program that redesigns its rotation goals and objectives in July will not see dramatically different evaluations scores by September. The faculty development initiative that launches in the fall will not transform teaching culture by spring.

This is where most structural improvement efforts stall. Leadership invests in the design work, the launch, the announcement. And then, when results don’t appear quickly, momentum fades. The new structure gets absorbed into the old culture. The explicit expectations become implicit again. The fee-for-all reasserts itself because no one stayed with the change long enough to let it take hold.

Sustainable improvement in educational structures requires someone with institutional authority and institutional patience to hold the line. To ask, in the annual program evaluation, whether the rotation looks the way it was designed to look. To follow up with faculty who were given explicit expectations and check whether those expectations are being met. To name, differently and without softening, when the structure that was built on paper is not the structure that residents are experiencing.

This is not the comfortable work. It requires a willingness to have difficult conversations with faculty who have practiced a certain way for years. It requires program directors to hold attendings accountable for educational responsibilities that may never have been clearly defined before. It requires institutional leadership to support that accountability rather than treating it is an administrative inconvenience.

But it is the work. And without it, every structural improvement eventually reverts to the mean.

A Practical Starting Point

If you are a program director or GME leader reading this and recognizing your program in what I have described, the path forward does not require a complete overhaul of everything at once.

Start with one rotation. Pick the one where the educational experience is most unclear, most variable, or most frequently the subject of vague or frustrated feedback. Sit with the residents who just completed it and ask them what the rotation actually looked like, not what the goals and objectives said it would look like.

Then build the structure that closes the gap between those two things. Document it specifically. Share it with the attending faculty. Make the expectations explicit on both sides. And then, three months later, go back and ask whether the rotation looks like what you desgined.

That cycle, repeated deliberately across rotations and over time, is how educational structure actually improves. Not through a single redesign effort but through the accumulated discipline of asking whether what we said we would do is what we are actually doing.

Progress will be slow. There will be rotations that improve and then slide back when a key faculty member leaves or a clinical volume spike changes the rhythm of the service. That is not failure. That is the nature of building something in a living, changing institution. What matters is that someone is paying attention, following through, and wiling to name when the structure needs to be rebuilt.

Share Sophia Gilmore, Ed.D., MPA

Closing Reflection

Graduate medical education exists to train physicians. Not to staff hospitals, not to move patient through the system, not to generate clinical revenue, though all of those things happen inside it. Its primary purpose is educational.

When the structure of a residency program cannot answer basic questions about what a resident’s week looks like, who is responsible for their learning on any given rotation, or what the explicit expectations are for the faculty supervising them, that purpose has been subordinated to other priorities. And the consequences of that subordination do not stay inside the educational relationship. They move through the entire institution, touching nursing staff, patients, and operational metrics in ways that are rarely connected back to their source.

The new academic year starts July 1st. Every program in the country is preparing for new reisdents to arrive.

The question worth asking before they do is not whether the orientation is planned or the schedules are distributed. It is whether the educational structure those residents are walking into was designed, deliberately, explicitly, and with someone committed to following through, to actually produce the learning it promises.

Lay the groundwork. Rise to the occasion.

The residents arriving this July deserve an environment that was built for them. So do the nurses working alongside them, the patients in their care, and the institution responsible for all of it.

Every June, as graduation photos are taken and farewell speeches delivered, a quiet but consequential moment arrives in graduate medical education.

The final evaluation.

Most programs treat it as a closing document. Milestones reviewed. Competencies confirmed. Paperwork signed. A chapter closed.

But what if the final evaluation wasn’t the end of something? What if it was the beginning?

The Missed Moment

Many residents who cross the graduation stage aren’t just finishing training. They are stepping into new roles as attendings, as leaders, as future faculty. And yet we rarely treat that transition with the weight it deserves.

The final evaluation, the individual learning plan summary, the milestone data accumulated over years of training, these documents hold a picture of a physician that extends far beyond what the checkboxes capture. They hold patterns of strength, ares of potential, and the early architecture of a professional identity that is still being built.

For programs focused on faculty retention, leadership development, or academic career pathways, this moment holds untapped potential. Residents who are staying on or entering academic medicine deserve more than a checklist. They deserve a launchpad.

Reimagining the Final ILP

What if we used the final evaluation and milestone summary not just to close a chapter but to open the next one? What if these tools became a strategic blueprint one that reflects not only where the resident has been but where they are capable of going?

That kind of document would look different from what most programs currently produce. It would ask different questions and capture different things.

Has this resident shown initiative in quality improvement projects or team management? Have they demonstrated particular strength in bedside teaching, feedback delivery, or mentoring junior residents? What topics genuinely light them up academically, and how might those interests align with departmental needs? Where will they need deliberate mentorship as they navigate the shift from peer to supervisor?

None of these questions are about perfection. They are about possibility. They are about building a bridge from the identity the resident is leaving into the they are becoming.

Turning Evaluations Into Faculty Onboarding

Final evaluations and ILP summaries can become the first page of a faculty development portfolio. Not a ceremonial document that gets filed and forgotten, but a living record that informs how a new attending is welcomed, supported, and challenged in their next role.

Imagine what the looks like in practice.

You have excelled in procedural teaching throughout residency. Would you like to co-lead intern simulation next year? Your feedback style is thoughtful and specific- how can we support you in in becoming a formal coach for junior residents? The equity project you led in your third year had real institutional impact- have you considered presenting it regionally or writing it up for publication?

These are not just nice conversations. They are acts of institutional imagination. They say to a graduating resident: we see you not just as someone beginning in the next chapter of what you are capable of contributing.

That message, delivered at the right moment, changes how a new faculty member understands their relationship to the institution they are joining.

The Lifecycle Lens

Faculty development shouldn’t start at orientation. It should begin in residency.

When we use lifecycle thinking, when we prepare residents for their next professional identity rather than simply celebrating the one they are leaving we create continuity that most programs currently interrupt. The resident who graduates without that continuity has to rebuild momentum from scratch in a new role. The one who graduates with it carries forward the best of what their training revealed about them.

The questions worth asking at the program level are straightforward, even if the answers required real institutional investment. Are we tracking not just what residents accomplished, but what they are ready to do next? Are we inviting residents into a mindset of career design rather than compliance? What structures do we have in place to catch and cultivate the transition from the trainee to colleague?

A Tool for the Conversation

To support this kind of transition conversation, I’ve developed a brief reflection guide for programs directors and faculty to use in final ILP meetings. It is designed to take the conversation beyond milestone completion into the territory of professional identity, faculty readiness, and next-chapter development.

It covers for areas: leadership patterns observed during training, teaching and mentorship strengths, scholarly interests and potential, and growth edges to address in the first year of practice. The goal is not a comprehensive performance review but a forward-looking conversation that treats graduation a a beginning.

If you would like a copy, reply to this post or reach out directly and I will send it your way.

Closing Reflecton

Residency is not a terminal station. It is a threshold.

When we treat the final evaluation as a doorway to deeper development rather than a sign-off on completed training, we reshape something fundamental about the culture of academic medicine. We signal that the institution’s investment in a person does not end when the certificate is handed over. That the relationship between a training program and they physician it produces is not transactional but developmental and that development does not stop at graduation.

The residents crossing that thresholds this June deserves more than a closed file.

They deserve an institution that already knows what they are capable of next.

Getting by is not the same as getting better.

Every spring, ACGME resident and fellow survey results land in program directors’ inboxes and in GME offices across the country. And every spring, a version of the same conversation happens in program meetings, in CCC discussions, in annual program evaluation cycles about what to do with scores that came back below where anyone wanted them to be.

I have sat in enough of those conversations to recognize the pattern. And the pattern is worth naming.

What the Threshold Actually Means

ACGME expects programs to use survey results in their Annual Program Evaluation process and respond to areas of concern. Many institutions set an internal threshold, commonly around 80% compliance, as the marker that triggers a required plan of action. The threshold exits for a reason. A score that falls below is not a rounding error or a statistical anomaly. It is a signal from residents and fellows, anonymously and collectively, that something in the learning environment is not meeting the standard it should.

At the institutional level, the GME office receives both program-level and institutional-level results. Which means the GME office often have a view that no single program has: the pattern across programs, the items that show up consistently below threshold, the gaps between what the institution believes about its learning environment and what the people training inside it are actually experiencing.

That view carries responsibility. And it requires honesty about what is being done with it.

The Pattern Nobody Talks About

Here is what I have watched happen, more often than I would like.

Survey results come back. A program has several items below threshold, some significantly below. The initial reaction is a combination of defensiveness and deflection. A few residents must be disgruntled. The cohort this year was particularly difficult. Things are already being addressed. The scores will probably be better next year.

Then the annual program evaluation arrives. The below-threshold items get noted. A brief narrative gets written with measured, careful language that acknowledges that concern without fully sitting with it. A plan of action gets documented that is just specific enough to satisfy the requirement and just vague enough to avoid real accountability. And the cycle continues.

What almost never happens is the harder thing: a genuine, uncomfortable examination of what the data is actually saying. Who is in the room when that conversation happens, and whether the people whose experiences generated the data have any voice in what comes next. Whether the plan of action is designed to improve the score or to improve the thing the score is measuring. Whether anyone will look back in twelve months and honestly assess whether anything changed.

Getting by is not the same as getting better. And in graduate medical education, the difference matters because the learning environment these scores are measuring is the environment shaping the next generation of physicians.

Why Genuine Response Is Hard

It would be easy to frame this as a problem of motivation or integrity. It is not. Most program directors and GME leaders genuinely want their programs to improve. The barriers to genuine response are real and worth understanding.

Low scores in certain categories, including faculty teaching, workload and psychological safety, require conversations that are uncomfortable and politically complicated. Telling a faculty member that residents don’t feel safe raising concerns in their presence is not a conversation most program directors are training to have, and not one that most institutions have created clear processes to support.

Institutional factors that drive low scores, including adequate resources, systemic workload issues, and cultural dynamics that have existed for years, are often outside the program’s control to address unilaterally. A program director who identifies a systemic problem and it brings to institutional leadership needs that leadership to take it seriously. When they don’t the program is left holding a score they cannot improve without authority they don’t have.

And the survey itself, while valuable, has limitations that programs sometimes hide behind. Small programs sizes create statistical volatility. A single outlier response can move a score dramatically. These are real methodological considerations, and they are also sometimes a convenient way to avoid looking too closely at what the data might be telling you.

The difficulty is real. It does not excuse doing just enough to get by.

What a Genuine Response Actually Looks Like

The programs and institutions that use survey data well share a few characteristics. They are worth naming not as a checklist but as a standard to measure against.

They resist the instinct to explain the score before they understand it. The first question is not “why did we score low here,” which almost always lead to external attribution. The first question is “what might residents be experiencing that generated this score,” which leads somewhere more useful.

They involve residents in the response. Not performatively, not a brief mention in a town hall that scores were reviewed and things are being worked on. Genuinely. What did you mean when you said this? What would improvement actually look like from where you sit? What would make you answer the question differently next year? Residents who are involved in the response to their own feedback become invested in the outcome in a way that no program-designed initiative can replicate.

They distinguish between items they can address at the program level and items that require institutional intervention, and they escalate the latter clearly and specifically. A program director who brings a below threshold score on workload to the GME office or DIO with a specific request is doing something different from one who notes the concern in the APE and moves on. The first creates institutional accountability. The second creates documentation.

They build plan of actions that are specific, measurable, and tied to a timeline that will be honestly reviewed. Not “we will continue to monitor,” which means nothing. Not “we have implemented changes to address this concern,” which describes an action without committing to an outcome. But: here is what we are doing, here is what we expect to see change, here is when we will look at whether it did.

And they come back to the data. Not to validate that the plan worked but to honestly assess whether the learning environment changed. Those are different questions. One invites confirmation. The other invites truth

What the GME Office Owes This Conversation

At the institutional level, the GME office has a responsibility that goes beyond collecting and distributing results.

It is in a position to see what no individual program can see: which concerns are isolated and which are systemic. Which below-threshold items appear across multiple programs and therefore reflect something about the institution rather than something about a single program’s leadership. When the pattern of results over multiple years suggests that nothing is actually changing despite documented plans.

That view creates an obligation. The GME office that receives institutional results, notes the below-threshold items, and waits for programs to respond on their own is not doing its job. The institutional perspective exists to connect dots that programs cannot connect from where they sit, and to bring those connections to the people with the authority to act on them.

This means presenting results to senior leadership not just as a compliance update but as a genuine picture of institutional learning environment quality. It means tracking plan of action follow-through across programs and asking, explicitly, what changed. It means being willing to say to a program director, to a DIO, to a CMO, that the data suggests something that a plan of action is not going to fix.

That is uncomfortable work. It is also the work.

Closing Reflection

The ACME residency and fellow survey exists because what residents and fellows experience in training matters. Not just for accreditation. Not just for scores. But because the learning environment they are in right now is shaping the physicians they are becoming, and the physicians they become will carry those formative experiences into every patient encounter, every team interaction, every institutional decision for the rest of their careers.

A score that below threshold is not a bureaucratic inconvenience. It is a message from the people closest to the learning environment that something is not right.

They deserve a response that takes that message seriously.

Not just seriously enough to document. Seriously enough to act. Seriously enough to come back and honestly ask whether anything changed. Seriously enough to sit with the discomfort about an environment that everyone, including program leadership, institutional leadership, and GME offices, has some responsibility for shaping.

Getting by is not the same as getting better.

The survey results are in. The question is what we are actually going to do with them.

Health system leaders are being asked to think differently right now.

Not just about the next quarter or the next budget cycle but about what kind of institution they need to be by 2035. What care they will deliver, where, how, and who will deliver it. The strategic questions are real and the urgency behind them is real.

A recent piece in Becker’s Hospital Review, developed in collaboration with PwC, laid out a compelling framework for how health systems should be thinking about the decade ahead. Four forces driving transformation. Four questions every provider leader should be asking. A clear argument that the days of incremental change are over and that the organizations that move decisively now will be best positioned for what’s coming.

It is a strong framework. And it is missing something important.

The Question That Doesn’t Get Asked

Of the four questions the framework poses what care is being delivered, where, how, and who delivers it; the last one is where graduate medical education lives.

The article addresses the “who” question through the lens of workforce optimization. AI augmentation. Eliminating routine work. Enabling clinicians to operate at the top of their licenses. Reimagining workflows so that the people delivering care can deliver more of it, more efficiently, with better support.

All of that is right. And none of it addresses where those clinicians come from.

The physicians who will be practicing in 2035 are in training right now. They are residents and fellows in teaching hospitals across the country, learning not just the clinical skills of their specialty but something harder to measure and more durable. How to think, how to lead, how to function under pressure, how to navigate the institutional environments they will spend their careers inside.

The training environment they are in today will shape the kind of physicians they become. The culture they absorb. The habits they form. The model of professional identity they carry into every institution they ever work in after this one .

No workforce optimization strategy reaches that far back. But graduate medical education does.

What GME Actually Produces

There is a tendency in health system strategy to treat graduate medical education as an accreditation obligation. A compliance function. Something that runs in the background, managed by a small team, reviewed annually, and escalated to senior leadership only when something goes wrong.

That framing fundamentally misunderstands what GME is producing.

Graduate medical education produces the physicians health systems will depend on. Not just their clinical competence, though that matters enormously but, their understanding of what institutional medicine looks like from the inside. Their tolerance for complexity and ambiguity. Their ability to work across disciplines, communicate across hierarchies, and function within systems that are imperfect and always will be.

It also produces something less visible but equally consequential: institutional culture.

The residents training in a health system today are watching how that institution handles difficult. How leadership responds to uncertainty. Whether the environment they are training in models the values it claims to hold. Whether the people responsible for their education are resources, respected, and empowered to do their work well or whether they are quietly absorbing complexity that the institution has never formally acknowledged.

That observation repeated across hundreds of residents, across years of training becomes the culture of medicine. And the culture of medicine becomes the quality of care.

The Gap Between Educational Mission and Institutional Strategy

Most health systems with teaching programs have an educational mission statement somewhere. It lives in a strategic plan, an accreditation document, a website page.

What is less common is a health system that has genuinely integrated its educational mission into its broader institutional strategy. That has asked seriously and with resources behind the answer: what kind of physicians it needs to produce in order to be the kind of health system it intends to be by 2035.

That question requires knowing what the institution intends to be my 2035. And it requires someone in the room when that conversation is happening who understands graduate medical education well enough to translate between the strategic vision and the educational infrastructure.

This is the gap. Not a lack of commitment to education, most teaching hospitals are genuinely committed. But a structural disconnection between where institutional strategy gets made and where educational decisions get made. Between the C-suite conversation about workforce and the GME office conversation about program composition. Between the long-range plan and the rank list.

Those conversations rarely happen in the same room. And the distance between them has consequences that compound over time.

What Alignment Actually Looks Like

Health systems that treat GME as a strategic asset rather than an accreditation obligation share a few characteristics worth naming.

They know what they need their physician workforce to look like in five to ten years by speciality, by skill set, by the kind of care their community will require and they have connected that knowledge to their training programs. They are not just matching residents because the system works that way. They are deliberately building a pipeline.

They resource their GME infrastructure as a leadership function, not an administrative one. The people managing that infrastructure have the authority, the support, and the institutional visibility to do their work at the level it actually requires. The DIO has a seat at the strategic table. The GME office has a direct line to the questions that matter.

They invest in the learning environment as seriously as they invest in the clinical environment. Because they understand that the two are not separate. The resident who trains in a well-functioning, well-led, thoughtfully designed educational environment is learning something about institutional excellence that they will carry into every place they practice.

And they recognize that the return on that investment is long. It does not show up in the next quarter’s operating margin. It shows up in the physicians who stay, who lead, who build the next generation of institutional culture from the foundation of what they experienced in training.

That is a long return. And it is a real one.

A Note on This Moment

Health systems are entering a period of significant leadership transition, strategic repositioning, and institutional recalibration. New CEOs are arriving with mandates to build for the future. Boards are asking harder questions about sustainability. Leadership teams are being asked to define not just what they do but what they intend to become.

This is precisely the moment to bring GME into that conversation.

Not as a compliance update. Not as an accreditation report. But as a strategic question: what is the educational infrastructure of this institution producing and is it aligned with where the institution is going?

The health systems that ask that question now and invest in honest answers will be better positioned for 2035 than those that don’t. Not because graduate medical education is the only thing that matters, but because the physicians it produces are the people who will be delivering care in that future health system.

You cannot optimize for 2035 without investing in the pipeline that gets you there.

Closing Reflection

Every strategic framework for the future of health systems eventually arrives at the same place: the people.

The technology matters. The care models matter. The partnerships and the financial structures and the digital foundations all matter.

But at the end of every shift, in every hospital, in every community this system serves, there is a physician- trained somewhere, by someone, in an environment that shaped them in ways they may never fully name; making decisions that determine whether a patient is safe, heard, and well care for.

Graduate medical education is how health systems shape that moment. Not directly, not immediately, but over years and across careers and through the culture that training environments quietly build.

The health system of 2035 is being trained right now.

The question is whether anyone building the strategy for the future has thought seriously about what the training looks like.

It is showing up in discussions about attendance tracking, mandatory check-ins and the kind of monitoring that follows medical students from lecture hall to clinical rotation. The concern being raised, and it is a legitimate one, is that somewhere along the way the culture of support crossed a line. That in trying to catch every student who might be falling behind, we began treating all of them as though they were.

I have been thinking about this for a long time. Not just as an observer of the conversation, but as someone who has lived on both sides of the line it describes.

What Care Without Boundaries Actually Looks Like

In helping roles, the instinct to support is not a flaw. It is often what draws people to this work in the first place. The coordinator who follows up on a missing evaluation because she knows the residents in overwhelmed. The administrator who walks a struggling student through a process they could have figured out themselves. The program staff member who quietly absorbs complexity so that the learner doesn’t have to.

These are acts of care. And they are also, in their accumulated wight, a kind of message.

The message is: I don’t fully trust you to handle this on your own.

I don’t think that message is ever intended. But I have come to believe it is often received. And over years of working in graduate medical education, I have had to look honestly at my own patterns and ask whether the support I was offering was actually serving the people I thought I was helping or whether it was serving my own need to be useful, to prevent failure, to smooth every rough edge before it became a problem.

The answer, more often that I was comfortable admitting, was both.

The Continuum Nobody Talks About

Professional identity formation does not begin in residency. It does not begin in medical school. It begins in the earliest moments when a learner is trusted or not trusted to navigate something independently.

Every interaction in a training environment sends a signal about what kind of professional this person is expected to become. A culture of excessive monitoring signals that autonomy is a privilege to be earned rather than a capacity to be developed. A culture of relentless hand-holding signals that struggle is something to be rescued from rather than learned through.

Neither of those signals is what anyone in medical education intends to send. But intention and impact are different things. And the gap between them is where professional identity either develops or stalls.

What I have watched happen at the graduate medical education level across institutions, across programs, across roles is the downstream consequence of this gap. Residents who do not know how to self-regulate because they have always had someone regulating for them. Physicians in training who become anxious when supervision is reduced not because they lack competence but because they have never been given the experience of trusting their own judgement. A generation of learners who are highly monitored, highly supported, and quietly uncertain about whether they can function without both.

This is not their failure. It is a systems failure. And it starts earlier than residency.

The Harder Question for Those of Us in Helping Roles

People who work in support roles in medical education- administrators, coordinators, GME staff, program managers, tend to be people who are genuinely interested in learner success. That investment is the best thing about this work. It is also the thing that most requires examination.

Because the impulse to help, when it becomes reflexive, stops being responsive to what the learner actually needs and starts being responsive to our own discomfort with watching someone struggle. And struggle, handled well, is not a problem to be solved. It is the process by which professional identity forms.

Over years of working in this space, I have had to develop a different question for myself. Not “how can I help this person right now?” but “what does this person needs to do this themselves?” Those are not the same question. And the shift between them, small as it sounds, changes everything about how you show up in a helping role.

It means sitting with discomfort. Letting a deadline lapse when the consequence is educational rather than catastrophic. Not sending the reminder email. Not walking someone through the form they could read themselves. Trusting that the friction they are experiencing is doing something. Building a capacity, clarifying an expectation, developing the self-regulatory habit that no amount of montioring will ever produce.

It does not mean withdrawing. It means being deliberate about when and how you step in. It means distinguishing between the support that opens a door and the support that carries someone through it.

What This Means for the Profession

Medical education is in a moment of genuine reckoning about what it produces. Not just what acknowledge its graduates carry, but what kind of professionals they become. Whether they are capable of independent judgement. Whether they trust their own assessment. Whether they understand that the responsibility of caring for patients cannot be outsourced to a supervisor, a system, or a support structure.

That formation happens across the entire continuum. In undergraduate medical education. In residency. In fellowship. In every interaction between a learner and the institution training them.

And it is shaped, more than we usually acknowledge, by the people who are not clinicians. By the coordinators and administrators and GME professionals who interact with residents and students every single day, who make hundreds of small decisions about how much to do for someone versus how much to trust them to do themselves.

Those decisions are not administrative. They are educational. And they deserve to be treated that way.

Closing Reflection

Supporting a learner well is not the same as making things easy for them.

The distinction matters because medicine is not easy. The environments they will practice in are not easy. The patients they will care for will not offer the kind of scaffolding that a well intentional training program might.

Professional identity forms i the space between the challenge and the support. Not in the absence of one or the other, but in the relationship between them. When someone is trusted enough to struggle, supported enough to learn from it, and given enough space to discover that they are more capable than anyone’s monitoring ever told them they were.

That is what we are trying to build. And it requires all of us, in every role, to examine what we are actually doing when we say we are helping.

The call come sin and it’s always a version of the same call.

A program coordinator mentions, almost in passing, that the program director and a faculty member have been meeting with a resident. There might be concerns about performance. They might be starting the documentation process. They might not. They aren’t sure what to do next.

Sometimes the call comes from the program director directly. Sometimes GME finds out through a coordinator who heard something in the hallway. Sometimes GME doesn’t find out at all until the situation has escalated to the point where a formal action is already being considered, and the questions becomes: what’s in the file?

The answer, more often than it should be, is not much.

And yet, almost always, people knew. They had known for a while.

Not All Struggling Looks the Same

Before anything else, it is worth naming something that gets lost in the urgency of these situations. Struggling residents are not a single category.

Some residents arrive in July having come through medical school without ever being taught how to write a note efficiently, manage a patient list under pressure, or organize their clinical thinking in real time. They are not failing, they are behind on skills that someone, should have taught them. and they are trying to catch up while simultaneously learning everything else residency requires. These residents often self-correct with the right support. What they need is coaching, early and specific, not a corrective action plan.

Some are struggling because of something happening in their lives outside the hospital. A family crisis. A relationship ending. Financial pressure. Grief. The kind of weight that follows a person into every room they enter. Their clinical performance may be suffering, but the root cause is not clinical. These residents need someone to notice. Genuinely notice before the performance concern becomes the only thing anyone sees.

And some residents have always found this kind of work genuinely difficult. The cognitive demands of clinical reasoning, the organizational complexity of managing multiple patients, the translation of what they observed at the bedside into coherent documentation. These are things they will need more sustained support to develop. They are not lost causes. But they need something more structured and more consistent than a single feedback conversation.

Three very different situations. And in many programs, they are handled the same way or not handled at all, until they can no longer be ignored.

What the Early Signs Look Like

The signs appear before anyone has named them as signs.

A resident who struggles to present patients in a way that tells a clear clinical story. Notes that don’t get closed. Charts that sit open at the end of a shift because the resident cannot synthesize what happened into a coherent narrative. Difficulty prioritizing when the list gets long and everything feels equally urgent. An attending who mentions something informally at the end of a rotation; not quite feedback, not quite a complaint, just a quiet observation that lands somewhere and disappears.

A coordinator who notices that a particular resident always seems to be the last one out. A nurse who mentions to no one in particular that something feels off. A peer who covers for a colleague more than seems normal and a doesn’t know how to say no.

These are not vague impressions. They are data. And they are almost never written down at the moment they appear.

They live in conversations. In the hallway, in the break room, in the informal debrief after a difficult shift. They are known; sometimes widely known and they do not make it into a formal record until the situation has reached a point where formal action feels like the only option left.

Why It Doesn’t Get Documented

The reasons are real and worth naming without judgement.

Faculty are uncomfortable with formal feedback that feels consequential. Writing down a concern about a resident feels different from saying it out loud, more permanent, more serious, more likely to define a person in ways that can’t be taken back. So the concern gets mentioned verbally and left there.

There is persistent hope that the resident will self-correct. Medicine has a long tradition of assuming that difficulty is temporary, that the demands of the environment will eventually produce the competence they require, that time and exposure will do what deliberate intervention might accomplish more efficiently. Sometimes this is true. Often it isn’t and by the time it becomes clear, the window for early support has closed.

There is genuine uncertainty about thresholds. Faculty aren’t always sure whether what they’re observing rises to the level of something that needs to be formally documented. They don’t want to overreact. They don’t want to be the person who flagged something that turned out to be nothing. And in the absence of clear guidance or a trusted process for raising early concerns, the path of least resistance is silence.

And underneath all of it, there is the the cultural reality of medicine: naming a struggling colleague, even a trainee, even with the best intentions, can feel like a betrayal. The instinct toward protection. Toward giving someone the benefit of the doubt, toward not making things harder than they already are is not callousness. It is, in its own way, a form of care. It just isn’t the form that actually helps.

What Happens When Programs Skip Straight to Corrective Action

When concerns that have been building for months finally surface formally, programs often move directly to corrective action plan, probation, or formal documentation without first asking whether other avenues have been tried.

This is where GME can and should be a resource and where the missed opportunity is most significant.

A corrective action plan is a tool. It is not a first step. Before a program moves to formal corrective action, there are questions worth asking: Has the resident received specific, documented feedback about the concern? Has anyone sat with them to understand what is driving the difficulty? Has a coach, a mentor, or a learning specialist been involved? Have GME been consulted? Have outside resources- counseling, academic support, professional coaching been offered and documented?

In many cases, the answer to most of these questions is no.

Programs reach for the formal process because it feels like doing something. And sometimes formal processes are necessary and appropriate. But a corrective action plan issued without prior documented support is not just a missed opportunity for the resident it is a liability for the program. It crates a record that begins with consequences rather than care, and that is a difficult record to defent when it matters.

The residents who are best served and the programs that are best protected are the ones where the documentation trail shows a thoughtful progression: early concern noted, support offered, progress monitored, outcomes reviewed. That trail tells a story of an institution that tried to help before it moved to hold accountable.

That story requires starting earlier than most programs do.

The Role GME Should Be Playing

GME sits in a unique position in these situations.

It sees across programs. It hears the pattern of concern that no single department has the full picture of. It knows which issues are common in the transition from medical school to clinical training. The note writing, the list management, the clinical reasoning under pressure and which one suggest something that needs more individualized attention. It has often seen versions of this situation before and has a sense of what has worked and what hasn’t.

That institutional perspective is a resource. And it is frequently underused.

When programs call GME after a situation has already escalated, the question is almost always backward. What do we do now? The most useful version of that question is the one that almost never gets asked: what should we have done earlier, and what can we do right now that isn’t just escalation?

GME can help programs think through what kind of struggling they are dealing with. It can connect residents and programs with outside resources-mental health support, academic coaching, professional development, before these resources feel like a last resort. It can help establish a documentation trail that reflects genuine support rather than sudden scrutiny. And it can provide the kind of institutional memory that helps programs understand they are not alone is what they are navigating.

None of these requires GME to adjudicate individual cases or override program authority. It requires GME to be genuinely available as a thought partner, a resource navigator, and an institutional memory before the situation has reached the point where options are limited.

What Earlier Identification Actually Requires

Earlier identification of struggling residents is not about surveillance. It is not about labeling people at the first sign of difficulty or creating a culture of heightened scrutiny that makes an already demanding training environment more anxious.

It is about building the conditions where early concerns can be named; specifically, behaviorally, tied to observable performance rather than global impressions in a way that opens a door rather than closes one.

A resident who has documented coaching conversation in month two, with clear observations and a plan for support, is in a fundamentally different position than a resident who has nothing in their file until month eight. So is the program. So is the institution.

The documentation, done well, is not a weapon. It is a map of where the resident started, what support was offered, how they responded, and what the nest step should be. That map serves the resident when things improve. It serves the program when they don’t. And it serves the institution when it needs to demonstrate that its processes were fair, deliberate, and genuinely oriented toward helping someone succed.

Closing Reflection

The residents who struggle in silence- whose difficulty is known but unwritten, discussed but undocumented, observed but unaddressed are not well served by the instinct to protect them from formal processes.

They are well served by institutions that notice early. That name concerns specifically and supportively. That offer real resources before reaching for corrective action. That understand the difference between a resident who needs coaching, a resident who needs support through a difficult personal moment, and a resident who needs a more structured intervention and respond accordingly.

The call that comes too late. The one where GME is asked what to do after months of informal concerns have accumulated into a crisis is a call that din’t have to come that way.

Building the culture and the processes that change when that call happens is not a paperwork problem. It is a leadership one.

And it starts long before anyone picks up the phone.

The Designated Institutional Official is one of the most consequential roles in academic medicine.

It sits at the intersection of clinical quality, educational mission, accreditation compliance, faculty development, institutional strategy, and organizational culture. It is, by any serious definition, a senior executive role.

And yet, the way academic medicine thinks about who should hold it has not fully caught up with what the role actually requires.

The Clinical Default

The tradition in graduate medical education is to place physicians in the DIO seat. There are real reasons for this. Clinical credibility matters. But tradition is not the same as strategy.

What the DIO role requires, in practice, is not primarily clinical. It is organizational. It requires the ability to manage complex multi-program enterprises. Expertise in accreditation systems. Strategic planning. Budget oversight. The capacity to translate educational mission into operational reality.

It requires, in short, the skills of an experienced organizational leader.

What the Field Has Overlooked

Graduate medical education has produced a generation of professionals who have spent their careers developing exactly the expertise the DIO role demands.

They have managed accreditation cycles across dozens of programs. Built the systems that make July 1 possible. Navigated institutional policies and regulatory complexity. Many hold advanced degrees in educational leadership, public administration, and organizational development. Specifically designed to prepare people for exactly this kind of institutional work.

And many of them have been passed over for DIO roles in favor of physicians who are excellent clinicians, but who often step into the organizational dimensions of the role without formal preparation for it.

The Evolving Reality of the Role

The DIO role of 2026 is not the DIO role of 2006. ACGME requirements have grown. Institutional expectations around wellness, DEI, and faculty development have expanded. The operational demands cannot easily be a secondary responsibility alongside a clinical practice.

The institutions navigating this most successfully have stopped treating GME leadership as a part-time assignment and started treating it as a full-time executive function that requires dedicated expertise.

Closing Reflection

The next generation of DIO leadership will come from multiple directions. The most forward-thinking institutions will evaluate candidates on the basis of what the role actually requires. Not what it has traditionally looked like.

And it will require the non-clinical GME professionals who have earned that expertise to make themselves visible with the quiet confidence of people who know the work from the inside. That case is worth making. The field is ready to hear it.

Share

Change in academic medicine moves differently than it does in other sectors.

It is not slow because people don’t care. It is slow because the systems are old, the stakes are high, and the people inside them have learned often through painful experience that most initiatives arrive with urgency and leave without follow-through.

I’ve led change in institutions that were ready for it. And in institutions that weren't. The difference is not always what you’d expect.

The Memory of Systems

Institutions hold memory.

Not in any formal way, not in documents or policies or strategic plans. In the quiet, persistent knowledge that lives in the people who stayed when others left. In the eye-roll that happens when someone proposes something that was proposed before. In the way a coordinator answers a question about process not with what the policy says, but with what actually happens.

When I have walked into under-resourced GME offices, the first thing I’ve learned to read is that memory. What was tried before and didn’t land. Who was burned by the last change initiative. Which departments will say yes in the meeting and no in the follow-through.

That intelligence is not available in any orientation. You build it by listening before you lead. By asking questions you don’t already know the answers to. By understanding that the resistance you’re encountering is often not about you or your idea. It’s about everything that came before you.

The Loneliness of the Institutional Perspective

Here is something I didn’t expect when I moved into institutional-level GME work: how isolating it can be to hold the view from above.

Program directors have their residents. Coordinators have their programs. Department chairs have their faculty. Everyone has a clear constituency, a clear mission, a clear measure of success.

The institutional GME leader has all of them and none of them, not fully. Your jobs is to see across programs, which means no single program sees you as entirely theirs. Your job is to hold institutional priorities, which sometimes means delivering a message that program doesn’t want to hear. Your job is to build systems that benefit everyone, which means no one department gets everything it wants.

You are, by definition, in the middle. And the middle is not always a comfortable place.

What I’ve learned is that the loneliness of the institutional perspective is not a problem to be solved. It is a feature of the role. The goal is not to be everyone’s ally. It is to be trustworthy to everyone which is different, and harder, and more durable.

Change Without Authority

The most challenging version of this work and the one I know most personally is leading institutional change without full institutional authority.

When you are the only person in a GME office, or the only one in the room with experience across multiple institutions. When the DIO is present but clinical responsibilities consistently pull more attention that GME ones, leaving the operational work to someone without the positional authority to move it forward. When one program has been setting the institutional tone for years and sees little reason to change. When the person closest to the work has never worked anywhere else and so genuinely believes that what exists is what is possible, not recognizing that other institutions have moved further, faster, with better tools and more current approaches.

That last pattern is quieter than the others but just as real. It shows up in resistance to new platforms, new workflows, new systems- not from malice but from the limits of a single frame of reference. When the way things have always been done is the only way anyone is the room has ever seen the done, change doesn’t just require a good argument. It requires trust, patience, and the willingness to show rather than tell.

In those situations, the instinct to push harder. To make the case more forcefully. To escalate.

Sometimes that’s right. But more often, what actually moves things is something quieter. Building one relationship at a time. Solving one small problem visibly enough that people begin to trust your judgement. Making the work better in ways that don’t require anyone’s permission, then making those improvements visible to the people who do have authority.

Change without authority is not passive. It is strategic patience. It is understanding that trust is the only currency that actually works in institutions and that trust is built slowly, in small denominations, long before it becomes the thing that makes the bigger change possible.

What This Work Has Taught Me About Leadership

The leaders I’ve respected most in the field are not the ones who arrived with the best plans. They are the ones who stayed curious long enough to understand the institution they were actually in and not the one they imagined.

They were honest about what they didn’t know. They build coalitions before they needed them. They named the resistance without making enemies of the resisters. They understood that changing a system requires cooperation of the people inside it and that cooperation is not given, it is earned.

That kind of leadership is not flashy. It doesn’t make for compelling conference presentations. But it is what actually works.

And in graduate medical education where the stakes are the training of the next generation of physicians, working is not optional.

Closing Reflection

Nobody tell you how hard institutional change work is before you do it.

They tell you about the strategy. The frameworks. The stakeholder mapping. The communication plans.

They don’t tell you about the Tuesday morning when you’ve followed up for the fourth time and still don’t have the answer you need. When the system you’re trying to fix resists you in every direction at once. When you wonder whether the vision you’re holding is worth the friction it’s creating.

Those are moments that define whether a leader is actually leading or just administering.

I’ve had those moments. I expect to have more of them.

But I also seen what happens when the work takes hold. When a system starts functioning the way it was designed to. When a resident arrives on July 1 and everything is in place. When the institution becomes, in some small and measurable way, better than it was.

That’s what keeps me in this work.

And that’s enough.

There is a pattern in graduate medical education that doesn’t get discussed at conferences or written into accreditation standards.

But those of us who have worked inside it know exactly what it looks like.

How it Usually Starts

A community teaching hospital earns accreditation. Program grow, often organically, often led by a strong department. Internal Medicine, almost always the largest, establishes its own rhythms early. It builds relationships with HR and IT on its own timeline. It develops onboarding processes that work for its residents. It coordinates across department because someone had to, and it did.

Over time, those program-level solutions become the institutional default. Not by design. Not out of resistance. Simply because a vacuum existed, and a capable program filled it.

Meanwhile, the GME Office-if one exists at all, inherits whatever structure remains. It is staffed lean. Sometimes by one person. It turns over more than it should, often filled by individuals who were operationally capable but came without deep GME specific experience.

The Program Mindset vs. The Institutional Mindset

Program directors are trained rightly to think about their residents. Their curriculum. Their outcomes. Their accreditation standards.

But an institution running multiple programs needs someone thinking differently. Someone asking: How does this decision affect the institution as a whole? Where do program-level solutions create institutional-level problems?

That is the role of a well functioning GME office. Not to override programs, but to see across them. When that office hasn’t been properly positioned, the gap between program thinking and institutional thinking widens quietly. Year after year. Until something forces the issue.

What Transitioning Actually Requires

Moving from a program-centered model to a cohesive institutional one is not a restructuring exercise. It is a change management challenge.

It requires senior leadership that understands what the GME office is actually coordinating, and is willing to give it the institutional authority to do that work. A GME office that has to ask permission from the department it’s supposed to align is not functioning as an institutional office.

It requires patience with Internal Medicine and every other program that has been doing things a certain way for years. The transition from program thinking to institutional thinking is an evolution, not a correction.

And it requires someone willing to do the unglamorous work building the institution from the inside. Establishing relationships before they’re needed. Creating systems that outlast any single person.

Closing Reflection

The GME offices that succeed are rarely the ones that started with everything perfect in place.

They are the ones when someone with the right experience, the right support, and the right institutional mandate decide to build on something that would last longer than their tenure.

Every residency programs completes one.

Most programs dread it a little. Some treat it as a formality. A few do it well.

The Annual Program Evaluation is, on paper, one of the most important documents in graduate medical education. It is the moment when a program is supposed to look honestly at itself as its curriculum, its outcomes, its faculty, its learning environment and ask whether it is actually doing what it was designed to do.

In practice, it is often something else entirely.

What the APE Is Supposed to Be

The intent behind the Annual Program Evaluation is straightforward and genuinely valuable.

Once a year, program leadership together with the Clinical Competency Committee, faculty, and often residents reviews the full picture of program performance. Board passage rates, Milestone data. Evaluation completion. Faculty development. Resident feedback. Learning environment concerns. The goal is not to produce a polished document. The goal is to identify what is working, what isn’t, and what the program intends to do about it.

Done well, the APE is a diagnostic tool. It surfaces small misalignments before they become citation-worthy problems. It creates a formal record of institutional self-awareness.

What is Often Becomes

Anyone who has sat in enough APE meetings knows the other version.

The language gets softened. “We had some challenges with duty hour compliance” becomes “we continue to monitor scheduling practices.” A pattern of unsatisfactory milestone ratings become “an area of ongoing focus and development.”

Here is what compounds this problem: those hallway conversations don’t stop happening just because they aren’t documented. The concerns get raised to GME, to the DIO, to institutional leadership; but verbally, informally, without a paper trail. The information exists. The institution just can’t use it.

Why it Happens

Accreditation anxiety. Programs that document significant concerns worry that honest self-assessment will trigger scrutiny. The instinct is to manage the narrative rather than tell the truth.

The culture of institutional optics. Program directors feel pressure to present their programs favorably. The APE becomes a performance rather than a reflection.

Discomfort with documentation. There is a particular hesitancy in academic medicine around putting concerns in writing.

CCC dynamics. When the CCC softens its conclusions, the APE has less honest data to work with.

What Gets Lost At Every Level

At the program level, problems that could have been addressed early become problems addressed late, under pressure, with less documentation and less room to maneuver.

At the institutional level, something equally consequential happens: the C-suite losses the evidence it needs to act. When a DIO or GME leader goes to senior leadership to make the case for resources, the conversation is only as strong as the documentation behind it. A request for additional GME staffing, remediation infrastructure, or faculty development support requires a documented record of need.

Undocumented concerns don’t disappear. They just become hard to address and harder to fund.

What Honest APE Processes Look Like

They have leadership that has explicitly separated the APE from punitive consequences. When program directors believe honest documentation will be met with support rather than scrutiny, the document honestly.

That culture is set from the top.

They connect the APE to the institutional resource conversation. What gets documented in the APE becomes the foundation for what gets requested from senior leadership. The two are not separate processes. They are the same argument, made at different levels of the organization.

Closing Reflection

The dirty laundry doesn’t disappear because it isn’t written down.

It just becomes harder to address. Harder to fund. And harder to explain when someone finally asks why nobody saw it coming.

Share

There is a particular kind of leadership that doesn’t get much attention.

Not the leadership of vision statements and strategic plans. Not the leadership of bold announcements and decisive pivots.

The leadership of staying steady when the outcome is genuinely unknown. When the system is imperfect. When the resources are insufficient. When the people around you are waiting to see what you’ll do next and you’re not entirely sure yourself.

Graduate medical education has been teaching me that kind of leadership for years.

Uncertainty Is Not a Gap in the Plan

In GME, uncertainty is the operating condition.

Every July, a new class of residents arrive. Some will exceed every expectation. Some will struggle in ways no interview predicted. Programs change. Accreditation requirements evolve. Institutional priorities shift. A faculty mentor leaves. A key coordinator transitions out. A process that worked last year quietly stops working and no one notices until something breaks.

Early in my career, I approached these moments as problems to solve, gaps to close, checklists to complete, contingencies to plan for. And those things matter. Systems thinking and operational discipline are not optional in this work.

But I’ve come to understand something that took longer to learn: uncertainty is not a failure of planning. It is the nature of working with people, inside institutions, through transitions that are by definition unpredictable.

The question was never how to eliminate it. The question was how to lead through it.

What Leading Through Uncertainty Actually Looks Like

It looks like holding a vision steadily while remaining genuinely flexible about the path.

In GME, I’ve watched leaders respond to uncertainty in two distinct ways. Some tighten their grip-more oversight, more process, more documentation as if control could substitute for clarity. The systems become more rigid precisely when they need to be more adaptive.

Others do something different. They stay visible. They communicate what they know and are honest about what they don’t. They make decisions with incomplete information and explain the reasoning. They absorb institutional anxiety without passing it down to the people doing the work.

Th second kind of leader doesn’t eliminate uncertainty. They make it navigable.

And in my experience, that is the different between a team that stays functional under pressure and one that fractures.

The Non-Clinical Perspective Is an Asset, Not a Gap

I want to say something directly, because it matters in the field I work in.

Graduate medical education has a long tradition of placing clinical leaders, physicians at the helm of its institutions. There are good reasons for that. Clinical credibility matters. Understanding the training environment from the inside matters.

But there is another kind of knowledge that also matters and it is less often named.

The knowledge of how institutions actually function. How departments coordinate, or fail to. How culture gets transmitted through processes, not just people. How change meets resistance not because people are obstinate, but because systems hold memory. How to read an organization’s behavior as a diagnostic to see not just what is happening, but why, and what it would take to shift it.

This is the work of organizational leadership. And it does not require a medical degree. It requires something different: the training, the experience, and the discipline to understand institutions as living systems and to lead them accordingly.

In GME, we ask physicians to take on administrative and executive leadership roles that are genuinely distinct from clinical practice. We ask them to manage compliance, culture, accreditation, strategy, and people; often without formal preparation for any of it. And we do this while sometimes overlooking the professionals who have spent their careers developing exactly that expertise.

I am not suggesting clinical leaders don’t belong in these roles. Many of them are exceptional. I am suggesting that the field benefits when it stops treating non-clinical leadership expertise as a secondary qualification and starts recognizing it as a different and equally necessary one.

What Uncertainty Has Taught Me About Institutions

Every institution I have worked in has been, in some way, a work in progress.

Some were under-resourced. Some were navigating leadership transitions. Some had systems that had calcified over time into processes nobody could explain but everyone was afraid to change. Some were doing genuinely good work inside structures that made that work harder than it needed to be.

In each of the, the question that mattered more was not: Is this institution perfect?

It was: Is this institution willing to look honestly at itself?

The ones that were, the ones where senior leaders asked hard questions and stayed with the answers, where GME offices were treated as strategic partners rather than administrative functions, where residents’ experiences were taken seriously as organizational data; those institutions grew. Not always quickly. Not always smoothly. But in the direction that mattered.

That willingness to look honestly at systems, at culture, at gaps is not a clinical skill. It is a leadership one.

And is what I have spent my career trying to practice.

Leading Forward

I don’t know exactly what the next chapter looks like.

What I know is this: institutions that will train the next generation of physicians well are the ones that invest in their infrastructure as seriously as their outcomes. That resources their GME offices as the strategic operations they actually are. That recognize leadership expertise in all its forms and build environments where that expertise can do what it was developed to do.

I want to help build those institutions.

That is not uncertainty.

That is intention.

Match Day is one of the most visible moments in graduate medical education.

Celebrations. Announcements. Photos of newly matched physicians sharing where they will train.

It marks the end of one chapter and the beginning of another.

But what Match Day doesn’t show is the system that makes July 1 possible.

The Work That Starts After the Envelope Opens

For GME offices, program leadership, and institutional teams, Match Day is not a finish line.

It' is a starting point.

In years of working in graduate medical education, I’ve watched the celebration photos go up on a Friday and by Monday, the real work has already begun. Credentials to verify. Visas to track. HR systems to coordinate. Licensure timelines that don’t wait for anyone.

Behind the scenes, a different kind of work takes shape: verifying credentials and onboarding documentation, coordinating across HR, IT, Employee Health, and Compliance, managing licensure timelines and visa considerations, preparing orientation schedules that vary across programs, and ensuring residents can function in clinical systems on day one.

Each of these steps is interconnected. And each one carries real risk if not done well.

Why a Missing Password is a Patient Safety Issue

Onboarding in graduate medical education is often treated like a checklist. Complete the forms. Schedule the sessions. Send the emails.

But in reality, it is a system. One that requires coordination across departments that do not always share timelines, priorities, or communication styles.

Small delays can create downstream consequences. A missing login can affect patient care. A delayed clearance can prevent a resident from starting on time. A fragmented orientation shapes how prepared or unprepared someone feels walking into their first clinical shift. These are not administrative inconveniences. They are patient safety issues in waiting.

When onboarding works well, it is almost invisible. When it doesn’t, everyone feels it.

The First Clinical Experience is Operational, Not Clinical

By the time a resident walks into the hospital in July, they are expected to navigate multiple systems, understand workflows, begin caring for patients, and integrate into a team; often all within the same week.

What we often overlook is this: their first experience of the institution is not clinical.
Is is operational.

It is shaped by how clear instructions are, how coordinated the process feels, and how supported they are in navigating complexity. That experience sets the tone for everything that follows. A resident who arrive oriented and prepared carries that confidence into their first patient interaction. A resident who arrives confused carries that too.

The People Who Make July 1 Happen

Much of this work is done quietly; by coordinators, by GME teams, by program leadership working across silos to make the system function.

It is rarely visible. Almost never celebrated. But is the difference between a resident who arrives confident and one who arrives confused and that difference follows them long past July 1.

Without this work, the transition form student to physician does not happen smoothly. It just happens and the resident absorbs the cost of every gap.

A Different Way to Think About Match Day

Match Day is not just about where someone is going. It is about what environments they are entering.

And that environment is shaped long before July 1- by systems that are coordinated or fragmented, by processes that are clear or confusing, by leadership that is proactive or reactive.

The institution a resident enters on July 1 is not built that morning. It is built in the months of quiet, unglamorous work that follow Match Day.

Closing Reflection

In graduate medical education, we often celebrate outcomes. But outcomes are built on infrastructure.

And some of the most important work happens after the celebration- quietly steadily, and most entirely out of view.

The success of the next generation of physicians depends not only on who matches. It depends on how well we prepare for their arrival. On the coordinators who track every document. On the teams who stress-test every system before a new intern ever logs in.

I was looking through old emails recently and came across one from my dad.

The subject line read:
”Spring hopes eternal and summer is yet to come.”

He had attached a recipe for lamb and eggplant kabobs. He wrote something like, “For when you light the grill.” It was late winter when he sent it. Still gray, still cold, but he was already thinking ahead.

He believed in seasons changing.

This time of year in graduate medical education feels similar.

Next week is Match Week.
On Monday, medical students learn whether they matched.
If they don’t they enter the Supplemental Offer and Acceptance Program (SOAP); a process that moves quickly and feel even quicker.
Programs that did not feel reassess, recalibrate and try again.

It is one of the most emotionally concentrated weeks in our profession.

Behind every notification email is a person who have invested years-academically, financially, emotionally in reaching this moment.

Some will feel relief
Some will feel grief.
Some will quietly pivot.

And yet, by July 1st, every summer, hospitals across the country will welcome new interns. New white coats. New ID badges. New beginnings.

Spring hopes eternal.
Summer is yet to come.

Match Week reminds us that medicine is seasonal. There are cycles of anticipation, uncertainty, recalibration, and renewal. Even when outcomes differ from expectations, forward motion continues.

In my work, I am reminded each year that optimism is not naivete, it’s resilience. It is the quiet belief that this season is not the final one.

Regardless of the outcome next week, the story is still unfolding.

And in this profession, that matters.

Many faculty- thoughtful, committed educators-unintentionally assess learners against an internal benchmark:

“What would I have done?”

That benchmark is shaped by:

• Their own training ear

• Local culture at the time

• Personal clinical style

• Speciality norms that may have evolved

• The supervisors who trained them

This creates a hidden variability:
Two excellent physicians may give completely different feedback on the same performance, not because one is wrong, but because their reference points differ.

Residents experience this as inconsistency.
Institutions experience it as “evaluation noise.”
Faculty experience it as frustration when learners don’t “apply feedback.”

The Shift We Need: From Personal Standard → Shared Standard

If we want feedback to drive development rather than confusion, institutions must move from individual interpretation to collective alignment.

That doesn’t mean scripting faculty.

It means clarifying:

• What competence looks like here

• Which differences are stylistic vs. safety-relevant

• Where flexibility is appropriate

• What we are intentionally trying to produce in graduates

Practical Ways to Operationalize Better Feedback

1. Separate “Clinical Safety” From “Clinical Style”

   Faculty should explicitly name which comments relate to:

   1. Patient safety/decision-making (non-negotiable)

   2. Efficiency or communication preference (variable)

   3. Personal style (optional adaptation)

   Residents learn faster when they understand which category they’re in.

2. Build Micro-Calibration Into Existing Meetings

   Instead of adding new workshops, use:

   1. Faculty meetings

   2. CCC discussions

   3. Case conferences

   Ask one simple question:

   “What are we actually expecting at this level?”

   Five minutes of shared discussion reduces months of mixed messaging.

3. Give Faculty Language That Anchors Feedback to Growth, Not Comparison

   Encourage phrasing like:

   1. “At this stage, we’re looking for…”

   2. “The next step in development is…”

   3. “Here’s why this matters clinically…”

   This shifts feedback from: “That’s not how I do it”

   to:

   “Here’s how physician grow into this responsibility.”

4. Make Expectations Visible to Learners

   Many programs define competencies internally but never translate them into lived guidance.

   Consider:

   1. A one-page “What Success Looks Like on This Rotation”

   2. Examples of strong performance at each level

   3. Shared language across evaluators

   Clarity reduces perception-based critique.

5. Train Faculty to Recognize Generational Drift in Training

   Medicine evolves quickly.

   What felt essential ten years ago may now be:

   1. Automated

   2. Team-based

   3. Digitally supported

   4. Less central to outcomes

   Faculty development should include reflection on how practice has changed, not just how to teach.

Why This Matters Beyond Education

Inconsistent feedback isn’t just an educational issue.
It’s an organizational one.

When expectations vary:

• Learners expend energy decoding culture instead of improving practice

• Programs struggle to measure growth accurately

• Institutions risk producing physicians shaped more by change than design

Clearer feedback systems don’t standardize people.
They stabilize environments so growth can happen intentionally.

A Reframe for Leaders

The goal of graduate medical education is not to reproduce how we trained.

It is to prepare physicians for a system none of us trained in.

That requires feedback grounded in shared purpose, not personal history.

Closing Thought

We don’t need better scripts for feedback conversations.
We need clearer agreement about what we are trying to build together.

Once that’s aligned, the conversations become easier for everyone.

Subscribe now

In graduate medical education, most of the work that matters is invisible while it’s happening.

Residents are the ones:

• Translating institutional policy into actual patient care

• Navigating new systems while still learning how to practice

• Carrying both responsibility and supervision at the same time

• Adjusting, hour-by-hour to expectations that can change from service to service

By the time their impact is measurable, the moment that required the effort has already passed.

That’s why a single “Thank a Resident Day” can feel both meaningful and insufficient.

Training doesn’t happen in milestones.
It happens in ordinary Tuesdays.
In pages answered.
In notes rewritten.
In feedback absorbed, sorted, and tried again the next morning.

If we want to truly support residents,
appreciation can’t just be annual.
It has to be operational:

• Clearer systems

• Thoughtful onboarding

• Consistent expectations

• Feedback that teaches rather than corrects

Gratitude in GME is not just something we say.

It’s something we design.

Every February, thousands of leaders gather for the ACGME Annual Conference.

There are plenaries, concurrent sessions, poster halls, hallway conversations, and more business cards exchanged than anyone remembers by Monday morning.

And yet, year after year, I hear the same quiet refrain afterward:

“That’s was interesting- but i’m not sure what do do with it.”

That’s the difference between attending as a tourist and attending as a systems thinker.

The Tourist Mindset

The tourist attends the conference looking for answers.

They:

• Go to sessions that confirm what they already know

• Gravitate toward familiar faces

• Take notes they never revisit

• Return home inspired, but unchanged

Tourists consume content.
Systems thinkers look for patterns.

The Systems Thinker’s Lens

A systems thinker attends with a different posture:

They are not asking:
”What’s the best session?”

They’re asking:

• What themes keep repeating across sessions?

• Where do accreditation, culture, and operations quietly intersect?

• What problems are multiple institutions trying to solve, but naming differently?

They listen for signals, not soundbites.

Prepare Before You Arrive

Systems thinking start before the conference begins.

Ask yourself:

• What are our current pressure points? (survey results, recruitment challenges, faculty engagement, wellness concerns)

• Where do we rely too heavily on individuals instead of infrastructure?

• What questions are we avoiding internally?

Then choose sessions that challenge your assumptions, not ones that feel comfortable.

Watch the Hallways, Not Just the Podium

Some of the most important data at ACGME doesn’t come from slides.

It comes from:

• The offhand comments during Q&A

• The quiet “we’re struggling with that too” conversations

• The patterns you hear when different institutions describe the same problem in different language

This is where systems reveal themselves.

Translate, Don’t Transplant

One of the biggest post-conference mistakes is trying to replicate what another institution is doing.

Systems thinkers don’t ask:
”How do we copy this?”

They ask:

• What problem was that institution actually solving?

• What conditions made that solution possible?

• What would our version need to look like?

Context matters. Always.

Bring It Home With Intention

Before you leave the conference, identify:

• One assumption you’re willing to challenge

• One system you want to examine more honestly

• One conversation you need to have that you’ve been postponing

Not five initiatives.
Not a strategic overhaul

Just one meaningful shift.

The Real Value of the Conference

The ACGME Annual Conference isn’t abut checking a box or staying current.

It’s about learning how to see your institution more clearly.

When you attend as a systems thinker, the conference doesn’t end when you leave, it changes how you notice patterns, ask questions, and lead long after you return.

And that’s where real improvement begins.

Closing Reflection

You don’t need to attend every session.
You don’t need to have every answer.

But if you leave with sharper questions than you arrived with, you’ve attended the conference exactly the right way.

Every winter, it arrives

The ACGME Resident and Fellow Survey opens, inboxes fill, reminders go out, and a familiar tension settles across programs and institutions.

Some leaders brace for impact.
Some worry about optics.
Others quietly hope the number won’t change too much from last year.

But the truth is this: the survey itself is neither the program nor the solution.

It’s a signal.

And like all signals, its value depends on how well we understand what it is and what it isn’t.

What the Survey Is

At its core, the ACGME Resident and Fellow Survey is a snapshot of perception.

It captures how residents and fellows experience key elements of their training environment at a particular moment in time:

• supervision

• duty hours

• patient safety and quality

• educational content

• professionalism

• wellbeing

• resources and support

Importantly it reflects, patterns, not individual stories.
It aggregates lived experiences into themes that can be compared:

• across programs,

• across specialities,

• and against national benchmarks.

When reviewed thoughtfully, the survey can:

• highlight areas of consistent strength,

• surface misalignments between leadership intent and trainee experience,

• and identify risks early- before they escalate into citations or site visits.

Used this way, the survey is a diagnostic tool, not a verdict.

What the Survey Is Not

The survey is not a full picture of the learning environment.

It cannot:

• explain why residents answered the way they did,

• capture nuance or context,

• reflect recent changes that haven’t had time to settle,

• or distinguish between systemic issues and isolated events.

It also can’t account for something leaders often underestimate:
how safe residents feel being honest.

In smaller programs, trainees may worry about being identifiable.
In larger ones, they may feel their voice won’t matter anyway.

Silence, neutrality, or “middle-of-the-road” answers down’t always mean things are fine. Sometimes they mean:

• “I’m not sure this will change anything.”

• “I don’t want to make trouble.”

• “I’ve learned to adapt.”

The survey can tell us what residents are experiencing, but rarely how it feels to live inside it.

Where Leaders Get Stuck

The most common mistakes institutions make is treating survey results as:

• a compliance exercise,

• a defensive document,

• or a scorecard to be explained away.

We see this when responses should like:

• “That’s not what we meant.”

• “Residents don’t see the full picture.”

• “They didn’t understand the question.”

Maybe.
But, perception is the learning environment.

If residents consistently experience confusion, friction, or lack of support, the system is teaching something, whether or not it’s intentional.

What the Survey Can Reveal If We Let It

When paired with curiosity rather than fear, the survey can surface deeper truths:

• Are policies clear in writing but confusing in practice?

• Do residents know where to go for help or only where not to go?

• Are wellness resources available, but culturally discouraged?

• Do feedback mechanisms exist without visible follow-through?

Often, survey results don’t point to dramatic failures.
They point to small, chronic misalignments. The kind that quietly erode trust over time.

Turning Data Into Dialogue

The most effective institutions use the survey as a starting point, not an endpoint.

That means:

• sharing results transparently with program leadership,

• contextualizing trends rather than reacting to single items,

• inviting residents into conversations about what the data reflects and what is misses,

• and pairing survey findings with other inputs: exit interviews, focus groups, duty hour trends, evaluation data.

This approach sends a powerful message:
”We’re not just collecting your feedback. We’re listening for meaning".”

The Real Question the Survey Raises

Ultimately, the ACGME Resident and Fellow Survey asks institutions a deeper question than any single domain score:

Are we welling to look honestly at how our systems are experience, not just how they were designed?

Accreditation bodies can prompt reflection.
Surveys can highlight patterns.
But culture changes only when leaders choose to engage with what the data is trying to teach.

Not defensively.
Not peformatively.
But intentionally.

Closing Reflection

The ACGME Resident and Fellow Survey doesn’t define an institution.

But how an institution responds to it does.

Used well, the survey becomes a mirror. One that helps us see where the learning environment is aligned, where it’s strained, and where residents and fellows feel supported, heard, and safe enough to be honest.

And that kind of environment can’t be measured by a survey alone, but it often starts there.