Transactional Competence, Reliability, and Trustworthiness: Essential Attributes of Successful Faculty and Residents

Transactional Competence Decisions

When a resident appears on July 1st, faculty have a hierarchy of expectations including timeliness, demonstration of advanced beginner-level knowledge and skills, commitment to learn and prepare, and a willingness to meet patient needs. During the first few months of residency, faculty rely heavily on these basic elements of the clinician as they demonstrate commitment to the care of patients and goals of the educational program.

When a resident appears on July 1st, they have a hierarchy of expectations of the faculty (and supervising residents) that follow a similar pattern. These initially center around the faculty’s demonstration of presence, establishment of organization of the teaching service, articulation of expectations, and demonstration of knowledge and skills of the discipline. These would be considered dimensions of transactional competence of the faculty.

Reliance Decisions

The reliance components of resident performance are also assessed rapidly by the faculty, and include truthfulness, learning about the clinical problems of their patients, the ability to recognize a patient who is deteriorating clinically, the willingness to admit what they do not know, and the ability to recognize when they need help coupled with a willingness to call for that help. When these components are judged to be present, the faculty then begin the process of assessing trustworthiness in increasingly sophisticated elements of the care of patients. Faculty can then tailor their oversight and case-by-case education to the level of academic development of each resident, fostering and encouraging the resident’s adoption of a growth mindset. Similarly, residents assess the faculty member’s availability, modeling of professional deportment, physician-patient relationship, knowledge and technical competence in the field, and consistent and fair evaluation of their progress and that of their colleagues. They observe and assess the faculty member’s interactions with interdisciplinary teams and assess their willingness to provide support in patient care decisions at all hours of the day and night.

Trust and Trustworthiness Decisions

The relationship may proceed to trust when the faculty demonstrate genuine desire to teach, model professional behavior, treat all members of the team with respect and fairness, and demonstrate empathy for the challenges that their residents face. Trusted faculty handle adversity with equanimity and effectively assist each member of the team in the achievement of their educational goals. They provide residents with a safe environment for learning from mistakes while protecting patients from significant errors in their care. They fairly and consistently evaluate each resident and provide truthful feedback on their performance. In circumstances where the resident is not meeting expectations for progress, remediation may be required, and its acceptance by the resident will largely be based on their trust in the fairness of the faculty and the effectiveness of prior feedback. Faculty must also acknowledge mistakes and receive feedback on the effectiveness of their educational efforts in a fashion that demonstrates professional commitment to excellence, improvement, and lifelong learning. In this fashion they demonstrate commitment to the educational process, and model professionalism.

As residents demonstrate increasing competence and reliability, the faculty proceed to entrust them with increasing independence. When patient care complexities and volumes are high, faculty trust residents to help maintain excellent patient care—sometimes in their absence. In this way, the ultimate purpose of residency is achieved. Faculty ideally come to trust that all graduating residents are prepared for independent patient care.

Importance of Trust and Trustworthiness

These bidirectional trusting relationships are essential in the highly performing residency program. When bidirectional trusting relationships emerge, high-quality safe clinical care can flourish, and education in the clinical learning environment can be optimized. As the academic year progresses, expectations for performance evolve as incremental growth is expected. These basic elements of transactional competence, reliance, and trustworthiness guide both the faculty and residents through this growth and underpin the satisfaction with and success of the program.

In our experience, there is an unfortunate reality. Residents (and faculty members) who demonstrate significant deficiencies in dimensions of transactional competence and reliance early in the year (or the first year of faculty membership) often have performance issues that are difficult to remediate and are fundamental disruptors of trusting relationships. Residents who are not truthful, who overestimate their abilities, are unreliable in executing clinical responsibilities, or fail to call for help when needed require special attention to assess and remediate these behaviors. Similarly, faculty members who belittle residents or other members of the health care team, demonstrate significant deficiencies in knowledge or skills in the discipline, refuse calls for help in the care of their patients, or unfairly and inconsistently evaluate resident performance should be remediated or considered for removal from teaching services.

Table 1 describes the symbiotic trust-requiring roles of the faculty and residents. These differ in many respects from those of the program director and residents. While there is a leader-subordinate relationship between the program director and the residents, there is opportunity for collegiality between the faculty and residents. This relationship is even closer in programs of longer duration, smaller programs, and fellowship programs, where advanced trainees bring highly developed skills and who work shoulder-to-shoulder with faculty in advanced care settings. These trusting relationships between faculty and residents spawn role modeling, mentoring, advising, and counseling relationships that enrich the lives of both the residents and the faculty, all hallmarks of an excellent educational program. Further, it is through harmonious and trusting practice that academic medical services achieve the mutual goal of excellent patient care. Specific tasks that are shared by residents and faculty based on the nature of their relationship are listed in Table 2.

Table 1Symbiotic Roles of the Faculty and Residents

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Table 2Tasks Shared by Residents and Faculty Based on the Nature of Their Relationship Required for Effective Education and Program Success

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Case 1

This program was on “Continued Accreditation with Warning” and had 2 years of declining performance on the Resident Survey in the domains of professionalism, faculty teaching, and supervision. At the site visit, the field representative interviewed the residents in separate groups by class, and individually when requested by some residents.

The program director also served as department chair and was characterized by the faculty as having significant influence and power among hospital leadership. The residents described a hierarchical structure within the faculty that was dominated by a few senior members and the program director. Junior faculty were assigned the majority of presentations at didactics, and senior faculty rarely attended didactics and journal club. The residents reported that senior faculty had preferential referrals of complex and more interesting patients, while junior faculty cared for patients with routine conditions. Senior faculty often made disparaging comments on patient rounds about management decisions made by their junior colleagues. The residents noted several examples of senior faculty criticizing the performance of junior and senior residents in public, including that they may not recommend them for competitive fellowships. The residents described instances of being berated verbally by senior faculty members in the presence of other residents and nurses. Residents assigned to the clinics of senior faculty described having limited autonomy, scant decision-making opportunities, and minimal teaching.

The residents agreed that they do not trust their faculty members to prioritize their best interests and to be advocates for their education. The residents said that when they made suggestions for program improvement, the program director usually said that their suggestions could not be implemented without further discussion.

Outcome, Case 1

The review committee issued “Probationary Accreditation.” With the support of the designated institutional official (DIO) and Graduate Medical Education Committee, the department chair agreed to relinquish leadership of the program. The special review performed by the Graduate Medical Education Committee identified a mid-career subspecialty faculty member who was respected and trusted by the residents and held in high regard by the faculty. Upon the appointment of the new program director, a series of meetings with the residents by class and as a group resulted in implementation of several positive changes. The faculty were required to attend faculty development sessions that focused on professionalism, active engagement in teaching, and participation in program didactics and journal club, giving timely feedback, and granting graduated autonomy. After the next ACGME site visit the review committee awarded the program “Continued Accreditation with Warning” and noted that the program was making positive changes, including improvement in the most recent Resident Survey. After a subsequent ACGME site visit the program was awarded “Continued Accreditation” and commended for substantive improvement.

Case 2

The review committee requested a site visit for this program on “Continued Accreditation” following 2 successive years of increasing dissatisfaction on the ACGME Resident Survey for professionalism and faculty teaching and supervision. Although the field representative offered individual interviews at the site visit, the residents chose to be interviewed by class.

The residents explained that hospitalists staffed each of the program’s 3 inpatient teaching services. The hospitalists, employees of a company that provided hospitalist services, were contracted to provide patient care without explicit requirements for teaching and oversight of residents. Nocturnists from a separate group provided weekend and nighttime coverage. Residents were assigned to the private offices of local physicians for their ambulatory clinical experiences. The residents contrasted this with hospital-employed subspecialty faculty who were dedicated and approachable teachers providing significant education. The program director, a subspecialist faculty member, did not have authority over the hospitalists’ and nocturnists’ work, including their teaching responsibilities.

Major issues with the role of hospitalists as described by the residents included: (1) lack of continuity of faculty on a given inpatient service; (2) minimal teaching on morning rounds; (3) senior residents having insufficient graduated autonomy to direct patient care; (4) hospitalists not providing timely verbal feedback to the residents; and (5) hospitalists not participating in resident didactics and educational conferences. The residents noted that they wanted hospitalists who were engaged in their education, provided mentorship to those who hoped to pursue hospitalist careers, and could be trusted to be resident advocates.

Outcome, Case 2

The review committee issued “Probationary Accreditation.” The subsequent site visit found that the program had made substantial progress in addressing areas of concern. The hospital employed a new hospitalist group and a chief hospitalist who had been a faculty member in a high-functioning ACGME-accredited program noted for excellence in teaching. The program director had authority over the hospitalists, appointed core and non-core faculty, and required them to attend faculty development sessions, provide teaching, and participate in didactics and clinical conferences.

The chief hospitalist was appointed associate program director. The postgraduate year 3 residents who had been in their first year at the time of the previous site visit were satisfied with the changes and reported that several residents had chosen hospitalists as their mentors. The review committee awarded the program “Continued Accreditation” thereafter.