Preserving professional credibility: grounded theory study of medical trainees' requests for clinical support

Abstract

Objective To develop a conceptual framework of the influences on medical trainees' decisions regarding requests for clinical support from a supervisor. Design Phase 1: members of teaching teams in internal and emergency medicine were observed during regular clinical activities (216 hours) and subsequently completed brief interviews. Phase 2: 36 in depth interviews were conducted using videotaped vignettes to probe tacit influences on decisions to request support. Data collection and analysis used grounded theory methods. Setting Three teaching hospitals in an urban setting in Canada. Participants 124 members of teaching teams on general internal medicine wards and in the emergency department, comprising 31 attending physicians, 57 junior and senior residents, 28 medical students, and eight nurses. Purposeful sampling to saturation was conducted. Results Trainees' decisions about whether or not to seek clinical support were influenced by three issues: the clinical question (clinical importance, scope of practice), supervisor factors (availability, approachability), and trainee factors (skill, desire for independence, evaluation). Trainees perceived that requesting frequent/inappropriate support threatened their credibility and used rhetorical strategies to preserve credibility. These strategies included building a case for the importance of requests, saving requests for opportune moments, making a plan before requesting support, and targeting requests to specific team members. Conclusions Trainees consider not only clinical implications but also professional credibility when requesting support from clinical supervisors. Exposing the complexity of this process provides the opportunity to make changes to training programmes to promote timely supervision and provides a framework for further exploration of the impact of clinical training on quality of care of patients.

Measuring Progressive Independence With the Resident Supervision Index: Empirical Approach

“…Quantifying supervision and measuring progressive responsibility have policy implications for defining supervision standards and measuring GME educational outcomes. 14 Building on previous work, [1][2][3]15 the RSI method consists of a survey instrument (RSI Inventory), 8 scoring strategy (presented herein), theoretical framework (patient-centered optimal supervision), 9 and analytic framework (2-part model). 9 This article shows how RSI Inventory responses were scored to quantify different levels of supervision intensity that, taken together, profile supervision during encounters among residents, attending physicians, and patients in outpatient care settings.…”

“…Before informing policy, however, more scientific research in actual teaching settings is needed to better understand the relationships among patient outcomes, clinic workload, case complexity, and graduate medical education experience in resident supervision and professional development. which the intensity of resident supervision is expected to decrease (1) for residents with longer lengths of GME training (progressive independence), (2) in clinics with more workload (workload effect), and (3) with patients who present with less complex medical problems (complexity effect).…”

“…The concept of graded responsibility for care and progressive independence from supervision has long been a model for graduate medical education (GME) [1][2][3] and has been incorporated into accreditation standards, policy statements, and supervision requirements. [4][5][6][7] However, no study to date has attempted to quantitatively estimate progressive independence in actual clinical settings as residents are promoted from one postgraduate year to the next.…”

The Call, the Save, and the Threat: Understanding Expert Help-Seeking Behavior During Nonroutine Operative Scenarios

“…1 A longstanding practice for a surgeon facing an unexpected intraoperative challenge is to call for the help of a coconsultant to prevent or reverse errors that may put patient lives at risk. 2 Although recent studies have explored the phenomenon of postgraduate trainees seeking help, [3][4][5] little is known about the determinants, processes, and consequences of consultant help seeking. This knowledge gap is problematic, because consultant help seeking is central to ensuring patient safety when experts find themselves at the edge of their competence.…”

“Page Me if You Need Me”: The Hidden Curriculum of Attending-Resident Communication

“…4,5,8,9 Early in their training, interns are driven by 2 main influences that minimize notification of their supervising physicians when they are uncertain. 7,10,11 Making calls, even to the attending physician, interrupts other team members, disrupts the workflow of the team, and decreases team efficiency. In addition, residents want to gain approval from their supervisors.…”