“How can I handle a difficult resident in my program?” asked a newly-appointed Chief Resident at a Q&A for Chief Residents.

Learning how to create positive resolutions with a problem resident or fellow can change the direction of their career. It can also enhance the quality of your own career and strengthen your program overall.

A Q&A was conducted on dealing with problem residents. While approaching the subject from a Program Director’s point of view, it should be made clear to new Chiefs that participation in creating solutions is of vital importance.

Problems with residents can arise in four general categories:

  • knowledge-base
  • clinical competence and judgment
  • surgical skills
  • professionalism


It is recommended that by establishing and implementing certain key actions, you, as Chief Resident, can keep these problems under control. These steps are:

  • outline your expectations clearly at the beginning of the year
  • document any deficiencies
  • provide timely counseling
  • provide appropriate remedial training quickly
  • follow up on your actions
  • initiate academic actions if necessary.

Outline expectations

Your goals and objectives for the year should be provided to your residents as a written document when they join the program.

Your written document should cover both the overall program and specifics on each rotation. It should be extremely detailed and should outline the specific requirements for advancement in the areas of knowledge-base, clinical competency and judgment, surgical skills, and professionalism.

Remember to consistently reinforce your message with personal contact. Residents should understand that their contract renewal is not automatic.

The best way to prevent the necessity of dealing with a problem resident is to preempt the problem from the start. A proactive approach to expectation medical management is the best way to accomplish this sometime tricky task.

Communicating and explaining the measurements for success is critical to making your program work. As a Chief Resident, you should expect the highest level of professional behavior from the residents in the following areas:

  • honesty and integrity
  • compassion for others
  • advocating for the patient in the physician/patient relationship
  • interpersonal relationships with families, support staff, other residents
  • ethical decision-making
  • proper personal hygiene
  • attendance, punctuality, work volume
  • acceptance of responsibility, particularly on-call response
  • compliance with institutional policies, i.e. records and licensing
  • collaboration – understanding limitations

Document Deficiencies

Some practical practice management advise to Chief Residents to provide written rotation evaluations and follow up with oral communications on any deficiencies noted. Chiefs should review the OKAP/in-service written examination results and seek faculty feedback on the resident’s surgical skills. It’s also important to document conference attendance, incident reports, medical records issues, clinical volume issues and licensing issues.

Provide Timely Informal Counseling

Early problems or isolated incidents can be handled informally (Level 1). Examples of this could include tardiness, poor surgical preparation, lack of response to calls or consultation requests. Timely, in person counseling may often be sufficient, and remedial actions should initially be educational rather than punitive – the resident should re-do the call or consultation. At this stage, it remains optional as to whether an official written entry should be put into the resident’s file.

“What about home and family problems?” one of the Chiefs asked. “I don’t want to punish someone for having personal problems.”

A proactive approach is best in this situation. As a Chief, you should be aware of your resident’s personal or family problems that might affect their work. Get to know them as people with family, friends and a life outside the training program. Meet with the resident and try to work out a solution before a crisis develops.

“What about two residents who just don’t get along?” asked another.

It’s generally not advisable to get too involved in other people’s personal differences. Your role as Chief is to be a role model – set the standards for appropriate behavior and make your expectations clear. And communicate them consistently and frequently.

“Will I need a lawyer if I find myself dealing with a serious problem?” asked another Chief.

The best legal protection and insulation from liability is always a commitment to thorough and ongoing documentation of potential problem situations. This “dedication to documentation” is crucial at all stages of resolving a problem with a resident. Dismissal from a program is serious, for all involved, especially the resident. If a legal action is brought upon your employer full and complete documentation of an ongoing problem will prove invaluable.

Formal Academic Actions

More serious, or repeated problems demand a frank and candid one-on-one meeting with the resident. The deficiency should be identified and documented, the method of correction and its timeline defined, and the consequences of noncompliance specified. All parties’ signatures are required, and remedial training assigned if indicated should be implemented.

Major deficiencies can lead to an escalating series of academic actions, including a Letter of Counseling (Level II), Notice of Concern (Level III), Probation (Level IV), Suspension (Level V), Non-renewal of Contract (Level VI), and Dismissal (Level VII).

Remedial Training

The timing of remedial training might vary from during rotations, to replacing an elective, to using vacation time, escalating to repeating a rotation after the rest of the class has graduated, or even repeating an entire year.

As Chief, you should be sure, at the beginning of the year, that residents understand the implications of formal academic actions and remedial training. These actions can seriously affect future letters of recommendation, including those for Board eligibility, credentialing and future employment. Post-residency fellowship eligibility may be delayed or denied. The overall reputation of the residency program itself can be adversely affected. These are all compelling justifications for following the core principles of defining expectations, ongoing communications, and a dedication to documentation, since there is a lot at stake when problem resident situations reach this level.

Remedial training itself can consist of supervised reading and tutorials, supervised clinical activities, increased surgery supervision, and additional supervised emergency experience.

What Can Chief Residents Do?

Be proactive. Outline your expectations in writing at the beginning of the year and be sure that the residents understand what’s expected of them. When you become aware of deficiencies, identify and document them and bring them to the attention of the resident. Provide timely counseling and remedial training, and follow-up diligently.

A central responsibility of your job as Chief is to recognize problems early and bring them to the attention of the faculty. Although some of the Chiefs expressed concern about being seen as a “snitch.” A Program Director will not be pleased at being blindsided and surprised if a major crisis develops without his prior knowledge. Chiefs should recognize that their goal is to improve the deficient behavior in the resident and to maintain the high standards of their program.

Scrupulous documentation is essential to the fairness and clarity of the process. As Chief Resident, you must take this responsibility seriously, right from the start, even with minor transgressions such as tardiness. This vigilant and consistent approach to documentation will establish the standards of your program clearly to all residents and other stakeholders. Just as importantly, it sets the framework within which you and your residents will develop and execute solutions that ultimately benefit and assist the problem resident and ultimately strengthen your program as a whole.

About the Author

Wesley D. Millican, MBA, is CEO and Physician Talent Officer of CareerPhysician, LLC, the national leader in child health faculty and executive search and leadership development. In partnership with the Child Health Advisory Council, a diverse group of emeritus and current national thought leaders in academic pediatrics, Mr. Millican provides critical career and professional development content to residents and fellows to help foster their effective transitions from training into academic and/or private practice roles. For more than 20 years, Mr. Millican and CareerPhysician’s Launch Your Career® Series has served as the trusted go to career training and ACGME Competency resource for U.S. residency and fellowship program directors, and most importantly for residents and fellows seeking to maximize their return on the personal, professional and economic investments and sacrifices made during training. Through Launch Your Career® Series onsite and visual programs and associated web-based content, Mr. Millican believes that residents and fellows are the future of academic pediatrics and that meaningful early investments in their career journey will have a monumental positive impact on their long-term professional satisfaction and their service to children.

For more information about the Launch Your Career® Series and/or to schedule a program for your residency or fellowship program, contact us.

Updated 2-14-24