Fellows’ Forum: 7 Tips to Successfully Manage Upward During Fellowship

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During the two or three short years of a rheumatology fellowship, there is so much to learn: the subtle art of the musculoskeletal examination, the intricacies of the immune system and the indications for a dizzyingly increasing array of new medications, to name just a few topics. One topic that you rarely hear about, but that gets to the heart of training, is upward management.

Upward management refers to the art of influencing those who have executive power over you.¹ Many fellows may be unfamiliar with the term, but most have an intuitive grasp of the concept. After all, fellows occupy a middle ground between residency and independent practice. They must learn not only how to supervise medical students and residents, but also learn how to deal with bosses—attending physicians, research mentors and program directors, among others. Surprisingly, not much has been written about upward management, especially in the medical setting. However, from my experience, here are some pointers to help build those skills.

1 Upward management is a form of empowerment: When I first read about upward management, I immediately recalled a whole host of people from junior high school up through residency who were, for lack of a better term, suck-ups. Their form of upward management was to please their bosses through any number of insincere, and occasionally humiliating, acts. I remember being appalled that they would justify their behavior by saying that things like, “It’s how to get ahead. It’s the only way to survive,” or “Everybody does it.” But upward management doesn’t need to be so degrading.

Believe it or not, fellows have a lot of power that is not always clearly seen. Leveraging that power wisely helps promote one’s own sense of dignity and builds capacity so that the helplessness and power asymmetry, which occurs in all training environments, becomes less of an issue. It may not feel comfortable to talk about the sense of conflict that comes inherently with being a subordinate to a boss—but it is important to acknowledge, even if you work in a very benign environment with a great boss. Indeed, how we make sense of this simmering conflict and how we assert ourselves in the relationship gets to the heart of upward management.

2 There’s more than one way to manage up: Before you know what you’re doing, you have to know who you’re dealing with. People, particularly physicians, are incredibly diverse in terms of attitudes, perspectives and backgrounds. So when you take two physicians, one trainee and one supervisor, that range of possible interactions becomes mind-bogglingly diverse. The key to successful upward management is to understand who you are and who your attending physician (or program director) is.