Imagine a bustling hospital ward where two medical residents, Dr. A and Dr. B, face the end of a grueling 12-hour shift. Dr. A decides to stay an extra hour to ensure that a complex patient handover is thorough and clear, demonstrating a commitment to patient care. Dr. A’s peers appreciate this because they are extremely busy themselves. In contrast, Dr. B, eager to end the shift and complete work before the duty hour limit, quickly delegates remaining tasks to junior residents, prioritizing personal relief over team cohesion.
Who did the right thing here?
The contrasting behaviors of Dr. A and Dr. B highlight the delicate balance between personal needs and professional responsibilities within medical training. This balance reflects broader challenges in medical education, where finding the right boundaries between individual wellness and collective accountability has become increasingly complex. Traditional aspects of medical training, considered essential for developing a high level of competence, are increasingly viewed through a lens of personal harm or injustice, possibly undermining the rigor of training.1
In the vignette, Dr. A appears to be committed to ‘not dumping’ on peers, and Dr. B. appears to be following the rules even if it disadvantages others.
In the context of medical training, horizontal accountability refers to the attitude of ‘we’ rather than the ‘me,’ emphasizing collaboration and shared decision-making. Vertical accountability, on the other hand, involves hierarchical relationships, such as those between residents and their supervising doctors or the hospital administration. It’s about adherence to the rules, guidelines, and decisions from above.2,3
What should educational leaders do to optimize behavior within a program?
It would seem tempting to prioritize selecting individuals with a strong horizontal accountability orientation as this is crucial for fostering a collaborative environment. As most program directors know, the risks of choosing those with a ‘me’ rather than ‘we’ orientation are substantial. Such individuals can ‘poison the well,’ creating an atmosphere of mistrust and competition. It only takes a few such individuals to disrupt team dynamics and compromise patient care.
But every upside has a potential downside.
Let’s look at the cases of Dr. A and B from a different perspective. Dr. A is known for being self-reliant, choosing to manage tasks alone. Dr. A believes that by doing so, they can ensure the work is done correctly and efficiently. However, this leads to an overwhelming workload and little time for collaboration or learning from others. Within this framework, Dr. A often feels unsupported by program leaders and speaks of this often in the resident lounge. In addition, Dr. A’s peers feel that Dr. A doesn’t trust them to care for patients. On the other hand, Dr. B delegates tasks to others. When they communicate well, Dr. B’s approach fosters a sense of fairness, respect, and community within the team.
Over-prioritization of horizontal accountability may diminish the perceived authority of leaders and disrupt the traditional hierarchical command structures necessary for decision-making and organizational coherence. Over-prioritization of vertical accountability can lead to abuses of trainees.
What to do then?
Polarity thinking offers a framework to manage this tension, recognizing that these two forms of accountability are interdependent and necessary for a well-functioning organization.4 Rather than choosing one over the other, polarity thinking encourages the integration of both, understanding that each complements and enhances the other. For instance, horizontal accountability ensures that residents feel a peer-supported environment encouraging mutual support and shared responsibilities. On the other hand, vertical accountability ensures that there is proper oversight, guidance, and feedback from higher-ups, which aligns individual actions with larger institutional goals. Managing the polarity between these accountabilities means acknowledging that too much focus on one can undermine the other, thus striving for a balance where both are optimized.
Unfortunately, there are no easy answers or blueprints for how programs should proceed.
Integrating accountability within a training program requires intentional structural and cultural efforts. Programs can foster horizontal accountability through peer-review sessions, group projects, and shared goals. Maintaining robust vertical accountability requires clear expectations, regular feedback from leaders, and formal evaluations.
The challenge lies in balancing each to create an environment where trainees feel equally responsible to each other and to their leaders.
Dr. A and Dr. B are present in every training program, each bringing their own strengths and weaknesses. We should strive for a balance that leverages the best of both.
References
- Rosenbaum L. Being Well while Doing Well – Distinguishing Necessary from Unnecessary Discomfort in Training. N Engl J Med.2024;390(6):568-572.
- Schillemans T. Accountability in the shadow of hierarchy: The horizontal accountability of agencies. Public Organization Review.2008;8:175-194.
- Moran V, Allen P, Sanderson M, McDermott I, Osipovic D. Challenges of maintaining accountability in networks of health and care organisations: A study of developing Sustainability and Transformation Partnerships in the English National Health Service. Soc Sci Med.2021;268:113512.
- Johnson B. Polarity management: Identifying and managing unsolvable problems: Human Resource Development; 1992.
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