Leading While Training: A National Survey of Embedded Chief Residents in Internal Medicine

Background: In internal medicine (IM), an increasing number of chief residents (CRs) are serving while still in training, but their responsibilities and workload remain poorly characterized, leaving program leaders without clear guidance on how to structure or support the role. Objective: To describe the demographics, responsibilities, and experiences of IM CRs serving during residency in the United States. Methods: This was a national cross-sectional survey of IM CRs serving during residency in the 2024-2025 academic year. The 42-item instrument included multiple-choice, Likert-scale, and open-ended items. Because no centralized database of CRs serving during training exists, the number of eligible participants was unknown. The survey was disseminated using a 2-step nonrandom sampling strategy: contacting leaders at 476 potentially eligible programs identified through national directories and distributing the survey through Association of Program Directors in Internal Medicine listservs. Descriptive statistics, chi-square tests, and Cochran-Mantel-Haenszel tests were used. Results: Of 165 respondents, 142 confirmed they were IM CRs serving during residency. Most were postgraduate year 3, non-White, and international medical graduates. Most trained in community-based programs and carried full clinical schedules. Weekly chief work varied, with 38% reporting 2 to 5 hours, 35% reporting 6 to 10 hours, and 14% reporting more than 10 hours. Common duties included enforcing program rules, coordinating backup coverage, and resident well-being support. Although 68% felt prepared for the role, less than half received written expectations (41%) or internal faculty-led training (39%). Conclusions: IM CRs serving during residency commonly maintain full clinical schedules while performing substantial administrative and educational responsibilities, with variable preparation and role expectations.