Rheumatology Fellowship Programs Could Benefit from Leadership Training

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The beep of the cellphone text got me off the armchair. I had been feeling cozy and comfortable. Outside the window, it was a blissful winter wonderland—the one, I believe, Nat King Cole intended when recording “The Christmas Song.” But at the same time, I was anxious to hear whether my clinic would be canceled due to the Monday morning blizzard raging outside. I was looking at yet either another snow/vacation day, or worse, the prospect of driving to work in my aging SUV with all-weather tires that I don’t believe adequately live up to their optimistic name.

With one eye on the TV meteorologist’s excitement over yet another New England snowstorm—in its full glory—a quick look at the incoming text prompted me to nearly faint. Despite heavy snowfall, my resident had made her way to the clinic this very morning. She was asking what time we were starting because it was already close to 9 a.m. and someone had told her that we might delay opening. I froze. I was physically comfortable and out of the elements in my warm home because, the previous evening, I had been advised that the clinic would not open until 10 a.m. The brave and devoted resident had just started her rotation with us, and the prior Friday, we had exchanged phone numbers just in case we needed to communicate about the anticipated Monday storm.

As I read her text, I panicked. At this moment, our lackluster communication plan was beside the point. What mattered was the powerful storm outside and news that close to a foot of snow had already fallen, making roads treacherous, and this young woman was stuck alone in an empty clinic. Because it was close to 9 a.m., the time we were supposed to get another update on clinic delays, I suggested she call the designated number about the storm update and stay put for now, adding that if she felt the roads were getting worse to leave right away. I hoped that she lived around the corner from the clinic. Of course, such was not the case. She lived at least 15 slippery miles distant. I envisioned her sliding from snowbank to snowbank as she traversed icy streets, justifiably cursing me for not notifying her of the clinic’s opening status in a timely manner.

My Fellowship Experience

This experience was a hard lesson learned for me, a recent fellowship graduate and new associate program director. During fellowship, our mentality was that we were to complete assigned tasks and follow defined schedules and rules. We were to be obedient followers, and those who performed well in that role probably were considered nicer, maybe better and easier to get along with. We showed up when told to, did our job and soon graduated. Fellows seldom are assigned tasks that test our sense of responsibility or exercise leadership/management skills.

During my fellowship, my program director insisted that we be responsible for making conference schedules, take control of who came to meetings, make sure that speakers showed up and see to it that topics were wisely chosen. That was a good start in creating the better, well-rounded leaders that we aspired to become after subspecialty training.

But what about properly managing and leading people in different and diversified professional settings? How about feedback concerning our leadership performance? I believe it is lacking in the current curricula and design of fellowship programs. Rather than complete fellowship with some experience in practical real-life leadership roles, we play catchup later on, mostly in the course of our jobs.

The winter storm provided me with such hands-on experience and humbled me with the realization that no longer am I responsible only for the safety and schedules of my family and myself, but also for a much broader scope of people: patients, the front desk, ancillary staff, colleagues, our students, residents and fellows. We may not often think about it, but many others do count on us for things other than medical care, treatment and administrative tasks. Those who work with us expect that things will be clearly communicated to them and that our expectations will be conveyed to them with a minimum of ambiguity.

Planning & Organization

In my experience, individual responsibility is not always clear or consistent in different circumstances, and it’s usually quite chaotic and stressful when no one knows who’s in charge and what is delegated to whom. Issues frequently arise regarding last-minute conference rescheduling, sick days and on-call coverage. It takes lots of planning, organization and professional behavior to make it all function somewhat smoothly. And, most of all, in my opinion, great flexibility is required to operate a well-run enterprise of teaching and patient care.

The snow emergencies don’t threaten every geographic area. We do, of course, have regions that enjoy relatively snow-free climates. However, even when I was in theoretically snow-free Texas, we had a paralyzing ice storm that revealed myriad problems for those who had to somehow figure out how to get to work over untreated roads. Even the sunny climes must deal with their own versions of emergency—floods, fires, earthquakes, tornados (Hello, Dallas!)—so the issues of preparedness and leadership won’t escape anybody in the medical field.

The dilemma over when and how to safely travel to work in inclement conditions is particularly challenging for the essential employees of our healthcare industry. I remember one of my junior colleagues, who was incredibly scared to drive on ice, but was still asked to see a consult during the ice storm. She told me that she literally feared for her life while traveling the icy local road. I now wonder, what would have been a practical solution to that scenario? Should the consult, if at all possible, be postponed? Should the attending physician, who presumably is more experienced and less petrified of winter driving, step up and do the consult alone? Perhaps the answer lies in communication, communication and still more communication.

The day after my Monday morning blizzard, the roads had been well cleared and looked awesome. I was elated just to be driving upon snow-free black pavement. I was sincerely appreciative of the municipal employees and plow operators who did their jobs all day and night so the rest of us could get out and do our jobs the following day. I had peace of mind knowing that my resident had returned to her home safe and sound the previous morning. I cannot stress enough how much weight was lifted from my shoulders upon learning that she had reached a safe harbor. I apologized for not being clear about the snow day plans. It likely will not be the last time I feel that I could have done better, but I also think the experience made it less likely a similar situation will happen on my watch again.

Lessons Learned

While thinking about these topics, I came up with few suggestions for how we can all be better leaders.

Suggestions for fellowship training leadership opportunities:

• Designate a chief fellow. Perhaps senior fellows can share the responsibility for a few months at time, take a role in communicating the on-call schedule changes and act as a liaison between director and other fellows.
• Help fellows be responsible for creating and maintaining the conference/lecture schedule.
• Advocate that fellows be part of hospital committees, at least in an advisory capacity.
• Create leadership opportunities in the community (e.g., participate in various food drives, marathons, lectures for the general population).
• Ensure that fellows and trainees have a regular and unopposed voice during conferences. Encourage them to ask questions and provide respectful answers.
• Meet with fellows and listen to their feedback regarding their own training.
• Delegate one fellow to represent the others during staff meetings.

Weather and other element planning tips:

• Create and publish to all employees a plan for weather and natural emergencies.
• Have a clear system about where the messages come from and at what intervals they will arrive, and identify who will follow up on the inevitable loose ends. Winter can be long and we can all get fatigued and sloppy, so we need to know when, how and where to ask for help.
• With the abundance of electronic devices and Internet, we must take advantage of using social media, pagers, mobile phones and e-mails in circumstances in which they can actually perform a practical function instead of being a mere means of entertainment or trivial communication.
• Particularly in view of the large number of female healthcare workers, we need to be aware of issues related to childcare responsibilities while schools are closed or delayed.
• Have a plan that addresses how to fairly treat and compensate those colleagues who manage to make their way to work when others cannot.
• Emphasize flexibility and advance preparation.

Next winter will be here before we know it!

Katarzyna Gilek-Seibert, MD, is a staff rheumatologist at Roger Williams Medical Center, Providence, R.I., and affiliated with the Boston University School of Medicine, in Boston. Contact her via e-mail at [email protected].