The Senior Resident-Fellow Dynamic on Pediatric Hospital Medicine Teams: A Qualitative Study

With the Accreditation Council for Graduate Medical Education accreditation in place for pediatric hospital medicine (PHM) fellowships, fellows are playing a larger role in resident education. However, the impact of PHM fellows on pediatric residency training is not well described. We aimed to identify the factors that affect the dynamic between senior residents and fellows working together on PHM teams.

In this qualitative study, we used purposive sampling and interviewed 15 senior residents and 8 PHM fellows between April and September 2020. We created a conceptual framework for the senior resident-fellow dynamic to develop the interview guide. Using verbatim transcripts uploaded into Dedoose software, 2 authors coded responses and identified themes using directed content analysis.

Twelve themes emerged as factors that impact the senior resident-fellow dynamic and fell into 6 categories: Team organization, role clarity, teaching, fellow approachability, decision-making, and attending involvement. Both senior residents and PHM fellows described an optimal dynamic in which a hierarchal approach to team structure, teaching, and decision-making is counterbalanced by fellow approachability. Role uncertainty, especially with increased attending involvement, led to conflict between residents and fellows.

This study demonstrated that a structured hierarchy surrounding supervision, decision-making, and teaching promoted level-appropriate autonomy for both senior residents and fellows. These findings can be used to design an intervention, such as a leadership curriculum for fellows and senior residents, to target behaviors that facilitate a stepwise approach to supervision and patient care.