#KeyLIMEPodcast 87: The autonomy of trainees; the safety of patients

The Key Literature in Medical Education podcast this week tackles a big issue facing Clinician Educators.  How do we balance increasing autonomy for learners (i.e. entrustment) to promote progression of competence, while minimizing risk to patients?  Current critiques of residency education is that there is no opportunity to practice in a mimic of a post-graduation environment (i.e. the unsupervised practice of a staff physician).  Thus, the transition from training environment to “real world” environment is abrupt and hazardous to physicians (and patients).  Juxtaposed against this challenge is the emerging patient safety movement that suggests the education needs of physicians-in-training cannot be at the expense of patient well-being.

While there are no easy answers in this paper, the findings from the study help  advance the field a bit further.  For a more extensive discussion, check out the podcast here.  Otherwise, check out the abstract below.

If you have a suggestion for a paper (or a topic) you can reach us here keylime@royalcollege.ca or leave a comment.

Jonathan

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KeyLIME Session 87 – Article under review:

Fri post_KeyLIME (Dr. Padmos)

Listen to the podcast

View/download the abstract here.

Naveh E, Katz-Navon T, Stern Z. Resident physicians’ clinical training and error rate: the roles of autonomy, consultation, and familiarity with the literature. Advances in Health Sciences Education: Theory and Practice. 2015 Mar; 20 (1): 59-71.

Reviewer: Linda Snell

Background
Residents are ‘inexperienced novice practitioners taking care of very sick patients while learning and mastering their profession’. Clinical training built in part on progressive autonomy (entrustment) but there is a fine balance between patient safety and the amount of supervision and learning. Residents are expected to call for help (’consult’ their supervisors) but often do not. They are also expected to know current literature. Experience is negatively associated with medical errors: junior (novice) residents have more errors than seniors. The work and training culture of surgery and medicine are different.

Purpose
To explore relationships between residents’ error rates and 3 factors in clinical training (1) level of autonomy, (2) consulting the physician on call, and (3) familiarity with medical literature, and whether these relationships vary between surgery and internal medicine and between novice and experienced residents.

Type of paper
Research: survey

Key Points on the Methods
3 different very short surveys in 2 hospitals to 142 residents, 83 nurses, 22 department heads and 30 senior physicians. Likert scale. Results anonymized. 80% response rate.

Analysis: hierarchical linear model (stats for modeling data or parameters that are organized or relate on >1 level, to allow examination of relationships of many levels / types of data simultaneously)

Key Outcomes
Unsurprisingly, level of autonomy, familiarity with lit, consulting appropriately all increased with year of residency, while perceived error rate decreased. In surgery, > autonomy associated with > errors; in surgery and novice IM residents, > consulting associated with < error; for all, familiarity with lit associated with < error.

Key Conclusions
The authors conclude that “the implicit curriculum that residents should be afforded autonomy and progressive independence with nominal supervision in accordance with their relevant skills and experience must be applied cautiously depending on specialization and experience… and … we should create a supportive and judgment free climate to reduce a resident’s hesitation to consult the attending physician.’

This is an excellent idea and research question however the survey methodology, providing only opinion, self-perceptions and indirect reports is disappointing and dilutes the significance of results. Nevertheless it makes us examine whether our assumptions about residency design, including progressive independence, providing time for reading, tacitly discouraging calling for help, need a second look. The provision of autonomy is also important these days as we look at entrustment and EPAs as a teaching and assessment approach.

Spare Keys – other take home points for clinician educators
Consider working within a research team with others with a totally different perspective e.g. here: engineering and business school.

Use the ‘best’ sources of data: for this question opinions and surveys can likely be supplanted by ‘harder’ data like knowledge tests, objective counts of consultations, and error rates from QI data.

Listen to the podcast here