Promoting Resident Autonomy

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How can physicians promote autonomy for the residents on their medical teams? And how might the presence of other learners such as fellows hinder resident autonomy? These are the questions Laura Goldstein, MD, is seeking to answer via her scholarship at Children’s Hospital of Philadelphia (CHOP).

Dr. Goldstein is a third-year Pediatric Hospital Medicine fellow who is also pursuing her Master’s in Medical Education (MSEd) at the University of Pennsylvania. As part of the clinical component of her fellowship, she works in the Division of General Pediatrics on the inpatient side along with attending physicians, residents – including senior residents, interns, sub-interns, and medical students. Noting that residents are “fiercely protective” of their autonomy, Dr. Goldstein says she does her best to promote their learning and put herself in an “attending’s shoes.” But despite her best efforts, she’s heard anecdotally that the residents feel as though their learning is being impacted.

“The residents perceived a decrease in their autonomy,” she shares. “Adding another layer of supervision [in having fellows on the team] made their autonomy feel compromised.” (This concept is rooted in self-determination theory, which posits that an individual must have some volition where their own learning is concerned in order to feel invested in the learning process).

While having fellows on different services is not new at CHOP, it could affect resident autonomy in inpatient General Pediatrics more than another division like Nephrology, for example. The inpatient General Pediatrics experience is the “backbone” of residency training, says Dr. Goldstein. Residents are expected to grow and become “experts” in the field, which may be difficult if fellows are making all of the medical decisions instead of letting residents have more room to lead.

In thinking about resident autonomy and its potential barriers, Dr. Goldstein’s scholarship was born.

First, an assessment

Dr. Goldstein reached out to Nicole Washington, MD, an attending physician in the Division of General Pediatrics, who is also the Associate Program Director of CHOP’s Pediatric Residency Program. Dr. Washington had data from previous scholarship she’d conducted on resident autonomy and allowed Dr. Goldstein to use this data as a needs assessment.

In reviewing Dr. Washington’s data, Dr. Goldstein learned that residents at CHOP as well as other institutions felt Pediatric Hospital Medicine fellows were “detrimental” to their autonomy. With this new piece of insight, Dr. Goldstein set out to identify the underlying problems within the Pediatric Hospital Medicine fellowship program and determine what she could do to promote resident engagement and well-being.

From there, Dr. Goldstein teamed up with Rebecca Tenney-Soeiro, MD, MSEd, Dorene Balmer, PhD, and Julianna Lau, MD (a CHOP resident) to launch her study.

The team recruited residents to participate, and then, Dr. Lau conducted virtual interviews with them via videoconferencing (BlueJeans or Microsoft Teams). Dr. Lau intentionally led the interview portion of the study, as it was clear residents wouldn’t be comfortable speaking with Dr. Goldstein since she is a Pediatric Hospital Medicine fellow. Then, Dr. Goldstein and her collaborators took the residents’ responses and transcribed them. They are in the process of analyzing the responses for common themes. At this time, it’s unclear what the study team will uncover.

Building rapport by videoconferencing

Similarly, Dr. Goldstein and her team are looking to recruit more residents to participate in the study over the next few months. Due to the COVID-19 pandemic, Dr. Goldstein is a little behind in terms of her study timeline. Maintaining hospital compliance and minimizing potential exposures to COVID-19 and “bare bones” staffing models where fewer fellows were working have also played a role.

Still, not all effects of the pandemic have been negative.

“The pandemic did force us to hold the interviews virtually,” says Dr. Goldstein. “But it made things easier in a way. Everyone was already comfortable using video-conferencing software.”

Holding the interviews virtually also made the conversations more “personal” than simply talking over the phone. And even though the virtual conversations were held face-to-face, the residents who participated were assured their identities would be protected, and subsequent data taken from the interviews would be anonymized.

Training as a PI

In addition, Dr. Goldstein appreciates the opportunity to serve as the study’s principal investigator (PI) and see things through from “start to finish.” This is Dr. Goldstein’s first time serving as a PI on a study, which she notes, is a “helpful experience to have during fellowship.”

And though Dr. Goldstein is unsure what she and her team will find in terms of responses upon completing the study, she predicts how things might go.

“We could find information to share with other institutions that indicate there are still some growing pains to address,” she notes. “There may also be an opportunity to partner if we see common themes and the data suggest others feel the same way. With the exception of the surgical literature, there isn’t a lot of literature on how fellows impact resident autonomy as it applies to other medical specialties and sub-specialties, so our findings could be applied across the board.”

Regardless of what Dr. Goldstein and her team wind up finding upon completing their study, she has some advice for other physicians:

“It’s important for all of us – fellows, attendings, and even senior residents – to be cognizant about how we are fostering our learners’ autonomy on a day-to-day basis. It’s important for learners to be able to practice clinical decision-making in a safe, supportive, learning environment. Even just being aware of how closely enmeshed autonomy and motivation can be, has impacted my practice, and I hope it has made me a more effective educator.”

In closing, Dr. Goldstein wants to clarify one thing about autonomy.

“Autonomy doesn’t necessarily mean a lack of supervision. Often, it just means allowing my learners to make clinical decisions within the structure of what is called ‘autonomy-supportive supervision’ and striking that balance correctly,” she says. “It also means letting my learners know their input is valid and valued; and reminding them that I’m there as a safety net. Autonomy and supervision aren’t opposites, and even residents who operate ‘autonomously’ are never truly alone.”