Progressive Independence in Clinical Training: A Tradition Worth Defending?

Abstract

There is limited empirical support for the current model of progressive independence in clinical learning; however, diverse theoretical perspectives raise concern about the potential educational consequences of eroding progressive independence. These perspectives could inform future research programs that would create a creative and effective response to the social and economic forces impacting clinical education.

Clinical Oversight: Conceptualizing the Relationship Between Supervision and Safety

“…supervision activities that is suited to policy development or empirical study. 1 Based on the current multifaceted definition of clinical supervision, 20 "increased" clinical supervision might involve such diverse changes as the provision of increased feedback to a trainee, the direct observation of an increased number of a trainee's clinical activities, or the performance of an increased amount of patient care activities by the supervisor. We do not propose to replace the multifaceted conception of clinical supervision, which genuinely reflects the multiple and complex roles that are filled by supervisors in clinical training programs.…”

“…The role of independence in clinical learning has some support in a variety of domains, but has yet to be adequately explored in the medical education literature. 1 The clinical oversight typology provided in this paper provides a starting point from which to develop a medical education research program that would address the relationship between various oversight activities, trainee autonomy, and clinical learning. For instance, consider how providing access to electronic test and imaging results could allow supervisors to keep abreast of developments in patients' conditions, through backstage oversight activities, without impinging on trainees' independence.…”

“…1 In the United States, Medicare rules and Health Management Organization guidelines often dictate the nature of the supervision that must be provided to trainees in order for reimbursement to be provided for clinical services. 2,3 In both the United States and Canada, resident work-hours restrictions have significantly decreased the amount of time that trainees spend in relatively autonomous on-call work.…”

“…17 These influences on clinical supervision practices have led to widespread increases in the supervision of clinical trainees. 1 At present, it is unclear what effect this increased clinical supervision has had on quality of care or patient safety and to what extent it might threaten the principle of progressive independence in clinical training (in which trainees are afforded clinical autonomy in accordance with their relevant skills and experience). 18,19 In part, this failure to develop a clear understanding of how increased supervision affects patient care and trainee learning has arisen because the concept of clinical supervision itself is multifaceted and poorly operationalized.…”

Measuring Progressive Independence With the Resident Supervision Index: Empirical Approach

“…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.…”