“I’m In It For The Long Game”: A Constructivist Grounded Theory Study of Residency Program Directors as Stewards of Accountability Paradox

Abstract

Background Although the Accreditation Council on Graduate Medical Education (ACGME) assigns accountability to program directors (PDs) and residents within the Common Program Requirements (CPRs), they do not define accountability and there is a gap in the literature regarding the role of individuals within the GME community in establishing and maintaining accountability. In an era of shifting individual and professional norms and expectations, it is not known how program directors navigate holding residents accountable during training, as a condition for their own accountability to residents, the institution, regulators, patients and the profession. Methods We performed a qualitative study rooted in constructivist grounded theory to explore how PDs navigated the mandate to hold residents accountable, using a lens of role theory. Data were collected using virtual, 1:1, semi-structured interviews. Recordings were transcribed and deidentified prior to analysis. Weekly meetings, concurrent memoing and coding by investigators allowed for constant comparison and iteration of interview questions to achieve satisfactory information power permitting theory development. Results Seventeen residency PDs at University of Washington, Mass General Brigham, and Tufts Medical Center participated in interviews between September 2025 and January 2026. Residency PDs navigated resident accountability largely as a hidden curriculum, although accountability was often conflated with expectations and responsibilities that were primarily task-based, and less characterized by feelings of responsibility. Participants encountered a range of irreconcilable and persistent core accountability tensions that caused role strain and required self-management yet were also generative. Participants reoriented themselves within tension anchored in prioritization of patient care, negotiating between the self and standard, and extending residents the benefit of the doubt. Tension was managed but not eliminated with actions centering ongoing engagement. Conclusion Accountability tensions are more accurately described as paradoxes that PDs steward on behalf of developing residents and evolving professional expectations, and their actions to manage tension are better described as paradox stewardship strategies. Residency PDs expressed a desire for enhanced preparedness for and training in stewarding role accountability paradox within the role and enculturating accountability explicitly with learners prior to GME arrival.