Trainee Autonomy and Supervision in the Modern Clinical Learning Environment: A Mixed-Methods Study of Faculty and Trainee Perspectives

Abstract

Background: Balancing autonomy and supervision during medical residency is important for trainee development while ensuring patient safety. In the modern clinical learning environment, tension exists when this balance is skewed. This study aimed to understand the current and ideal states of autonomy and supervision, then describe the factors that contribute to imbalance from both trainee and attending perspectives. Methods: A mixed-methods design included surveys and focus groups of trainees and attendings at three institutionally affiliated hospitals between May 2019-June 2020. Survey responses were compared using chi-square tests or Fisher’s exact tests. Open-ended survey and focus group questions were analyzed using thematic analysis. Results: Surveys were sent to 182 trainees and 208 attendings; 76 trainees (42%) and 101 attendings (49%) completed the survey. Fourteen trainees (8%) and 32 attendings (32%) participated in focus groups. Trainees perceived the current culture to be significantly more autonomous than attendings; both groups described an “ideal” culture as more autonomous than the current state. Focus group analysis revealed five core contributors to the balance of autonomy and supervision: attending-, trainee-, patient-, interpersonal-, and institutional-related factors. These factors were found to be dynamic and interactive with each other. Additionally, we identified a cultural shift in how the modern inpatient environment is impacted by increased hospitalist attending supervision and emphasis on patient safety and health system improvement initiatives. Conclusions: Trainees and attendings agree that the clinical learning environment should favor resident autonomy and that the current environment does not achieve the ideal balance. There are several factors contributing to autonomy and supervision, including attending-, resident-, patient-, interpersonal-, and institutional-related. These factors are complex, multifaceted, and dynamic. Cultural shifts towards supervision by primarily hospitalist attendings and increased attending accountability for patient safety and systems improvement outcomes further impacts trainee autonomy.

Ambiente educacional y aprendizaje autorregulado de los residentes de pediatría de un hospital especializado durante la pandemia por COVID-19

“…En las primeras etapas del residentado, los médicos ingresantes tienen como mentores a los residentes de años mayores y asistentes, quienes dan su retroalimentación y despiertan el sentido crítico en las discusiones de casos clínicos nuevos. Asimismo, el desarrollo de su autonomía, demostrado en su labor diaria, es fundamental para desarrollarse profesionalmente y mejorar el vínculo con los otros participantes del contexto hospitalario donde se desarrolla el residentado, como lo describen Domínguez et al 25 , Crockett et al 26 y Conner et al 27 Estas interacciones y los intereses personales de los residentes los llevan a elegir o priorizar sus estrategias cognitivas reflejadas en los objetivos de aprendizaje que ellos mismos se plantean y también las técnicas que utilizan para alcanzarlos. Esto es similar a lo descrito por Gaxiola et al, 15 quienes afirman que mejores relaciones académicas entre estudiantes pueden generar mejores compromisos académicos, lo que regula su propio proceso de aprendizaje.…”