Surveys were sent to 182 trainees (63 PGY1s, 64 PGY2s, 55 PGY3s) and 208 attendings across the three inpatient sites. Seventy-six (42%) trainees and 101 (49%) attendings completed the survey (Table 1a). Fourteen trainees (8%) and 32 attendings (32%) participated in focus groups (Table 1b).
Table 1
Demographic characteristics of participants in surveys (a) and focus groups (b).
| a. Survey participants |
| Trainees | n (%) | Attendings | n (%) |
| Level of training | 76 (100) | Experience post-training (years) | 101 (100) |
| PGY-1 | 19 (25) | 0–5 | 38 (38) |
| PGY-2 | 27 (36) | 6–10 | 22 (22) |
| PGY-3 | 30 (39) | 11+ | 41 (41) |
| Gender | | Gender | |
| Male | 35 (46) | Male | 45 (45) |
| Female | 41 (54) | Female | 55 (54) |
| Prefer to self-describe | 0 (0) | Prefer to self-describe | 1 (1) |
| | | Primary clinical site | |
| | | Quaternary care hospital | 48 (48) |
| | | Public county hospital | 26 (26) |
| | | Veterans Affairs hospital | 27 (27) |
| b. Focus Group participants |
| Level of training | 14 (100) | Experience post-training (years) | 32 (100) |
| PGY-1 | 1 (7) | 0–5 | 12 (38) |
| PGY-2 | 7 (50) | 6–10 | 10 (31) |
| PGY-3 | 6 (43) | 11+ | 10 (31) |
| Gender | | Gender | |
| Male | 5 (36) | Male | 15 (47) |
| Female | 9 (64) | Female | 17 (53) |
| Prefer to self-describe | 0 (0) | Prefer to self-describe | 0 (0) |
| | | Primary clinical site | |
| | | Quaternary care hospital | 18 (56) |
| | | Public community hospital | 3 (10) |
| | | Veterans Affairs hospital | 11 (34) |
Survey Results
Across all clinical sites, trainees perceived the current culture to be significantly more autonomous than attendings (Table 2). However, both attendings and trainees described an “ideal” culture as more autonomous than the current state, though trainees favored more autonomy than attendings. The largest difference between current and ideal state occurred at the quaternary referral center, which was perceived to be highly supervisory by both groups.
Table 2
Comparison of trainee and attending perceptions of current versus ideal culture by training site from entirely autonomous (0) to entirely supervised (1).
| Primary Clinical Site | Current culture Mean (SD) | Ideal culture Mean (SD) |
| | Trainee (n = 90) | Attending (n = 101) | p-value | Trainee (n = 90) | Attending (n = 101) | p-value |
| Quaternary referral center | 0.42 (0.5) | 0.77 (0.42) | < 0.001 | 0.11 (0.32) | 0.27 (0.45) | 0.02 |
| County hospital | 0.15 (0.36) | 0.48 (0.51) | < 0.01 | 0.30 (0.47) | 0.02 |
| VA hospital | 0.18 (0.39) | 0.38 (0.50) | 0.04 | 0.38 (0.50) | 0.01 |
Figure 1 summarizes attending and trainee perspectives of attending contributions to rounds by survey responds. There was good agreement between both groups that attending presence on rounds improved patient safety and trainee education on rounds, resident autonomy was important during the assessment and management of acutely ill patients and during consultant communication, and attendings should review necessary data independently in the Electronic Health Record (EHR). However, attendings valued a more supervisory role in new patient encounters, while trainees expected more autonomy (p = 0.04). Five themes arose from analysis of the six clinical scenarios and open-ended survey questions as core contributors to the autonomy-supervision dynamic: attending-, resident-, patient-, interpersonal-, and institutional-related factors (Appendix 4). Identifying these themes informed development of subsequent focus group questions.
Focus Group Results
Focus group analysis of the five core contributors to the balance of autonomy and supervision revealed a complicated dynamic. We identified subthemes within each core contributor to better understand the multiple variables that influence the balance of autonomy and supervision in the inpatient clinical learning environment (Fig. 2). Representative quotes for each subtheme are summarized in Table 3.
Table 3
Representative quotes from focus group participants describing subthemes of core contributors.
| Core Contributor | Subtheme | Representative Quote |
| Attending | Style & Practice Patterns | “I do think that autonomy is very important. I do believe you have to make mistakes. The most I've learned in residency was from mistakes I've made… trying to constantly protect the residents from making a mistake I don't think is effective.” (attending) |
| Impact of Training | “I do remember situations during my training where I did feel overwhelmed overnight or with new admissions…and feeling that tension of not knowing when to reach out to someone for help, and having some moral distress with that and trying to balance doing things on my own versus doing right by patients. I try extra hard to create an environment in which the learners know that they can approach me… because I wouldn't want them to be in that situation or to have that distress.” (attending) |
| Professional Identity | “When you're an attending, you wear the hat of a clinician first and foremost, hopefully. But then you are a supervisor, a mentor, you're psycho-social support, and a teacher…You're trying to do well at the same time. Knowing that you have to be on your A game every day. You're not allowed to have an off day as an attending.”(attending) |
| Clinical Experience | “When an experienced hospitalist is letting me be autonomous in a situation…[I trust] that they know what the boundaries of safety and effectiveness are…I have a harder time accepting autonomy from people who I know don't necessarily attend as much - specifically because it may not be a skill that is as frequently practiced for others.”(resident) |
| Trainee | Understanding Limitations | “The most important thing is to know when you need help. I find that attendings will give residents a little bit more leeway when they know if they're out of their depth, or if they're uncomfortable, they'll ask for help.” (resident) |
| Clinical Skills | “A foundational characteristic…is the ability to communicate, so communication skills with me as the attending, with the nursing staff, with other ancillary staff, and of course with the patient as well. I think that that is just a foundational component I look for in the learner, and if they do well in that domain then typically I feel more comfortable [granting autonomy].” (attending) |
| Team Leadership | “Listening to interns present, making mental notes of things that are inaccurate or not addressed yet you’re interested in, residents I feel comfortable with allowing autonomy will hit each of those point by point.” (attending) |
| Patient | Medical Complexity & Acuity | “I actually have had some attendings say to me "I'm very close right now because I'm personally uncomfortable in this situation, not because I don't trust you." And it was a hugely impactful moment for me as a trainee…to know that we both feel uncertain, rather than you feel uncertain in me.” (resident) |
| Special Populations | “People who are at high risk of [being] vulnerable to poor outcomes, I give a lot more supervision about how you advocate and do things for patients. I feel like people need a lot more education and micromanaging in how we do things properly for very vulnerable populations.” (attending) |
| Interpersonal | Role Expectations | “I just have some days where attendings felt like they were being helpful, but then they would do a task that actually I wanted to do, and it felt like it took away my autonomy. I think it's just hard to find a balance…if there's not good communication around what is helpful, it feels like they are taking away something that is important to my role.” (resident) |
| Dynamic Supervision | “The biggest challenge for me in a supervisory role is the ratcheting between the incredibly detail-oriented nature of the intern (when my interns are off) and the supervisory, big-picture needs of the resident when you're actually supervising. The more times when I am toggling between those two roles, the more difficulty I have as a supervisor giving my trainees autonomy.” (attending) |
| Patient Logistical Complexity | “If the patient has a plan that's being driven a lot by [a] specialty attending, then there's often these high-level conversations that are happening attending-to-attending that … I find myself just pulling back. I'm not going to make any headway myself with this patient if all the conversations are happening [at the attending level].." (resident) |
| Institutional | Culture | “I think there's a real idea of culture like, "Attendings like us supervise residents like this"... there's a large pressure culturally to be involved as junior faculty because your other junior faculty colleagues are more hands-on, and that's what has developed the culture for the residents.” (attending) |
| Residency Organization | “When we spend very little time together all as a team, the attending ends up being the person with the most continuity in the team. And so, they sometimes have…the most information, and are in the most informed place to help make decisions. But I think that that gives us less autonomy, because we know less about the patients, potentially. And part of that is the discontinuity of the team.” (resident) |
Attending Contributions
The attending contribution to the autonomy and supervision dynamic was multifaceted, incorporating their practice patterns, reflections from their residency training, and experience navigating the various, and often changing, roles that they are expected to fulfill within the team and institution. There was a near universal intention of restraint in order to create space for trainee clinical decision-making, though execution varied significantly depending on attending risk tolerance for trainee mistakes and flexibility in creating patient care plans. Trainees often were unable to distinguish discomfort with patient-related factors from discomfort with their own clinical skills, which seemed to exacerbate a negative reaction to perceived hypervigilance or “inappropriately” supervisory behaviors and amplify benefits of attendings’ intentional flexibility in clinical decision-making.
Attendings’ perspectives on the value of autonomy and supervision often related to experiences from their own residency training. Many attendings voiced support for resident autonomy due to perceived benefits to their own clinical growth from autonomous practice in residency or were able to identify supportive supervisory behaviors that helped ease workload or navigate specific challenges during their training. In general, attendings were motivated to emulate positive experiences and avoid distressing ones (most often related to inadequate supervision) as a guide to how they approached autonomy and supervision in their own practice.
Attendings described supervising inpatient resident teams as increasingly challenging, with a multifaceted and dynamic role that required adjustments even over the course of one rotation with a given team. They described feeling pressure to ensure high-quality patient care while also satisfying roles as an educator, supervisor, role model, and mentor. Many attendings and trainees identified that expectations for engagement with trainees varied by gender, level of clinical experience, and primary specialty (hospitalist versus subspecialist or outpatient physician). Female attendings expressed more difficulty earning respect and trust from trainees than male counterparts, particularly when their resident was male. Universally, attendings and trainees reported that junior attendings tended to behave or be perceived as more “hands-on” and engaged than senior attendings. This behavior was hypothesized to be related to clinical uncertainty or anxiety, though many attendings cited perceived expectations from trainees as the reason. Trainees were less likely to identify level of clinical experience as a determinant of engagement, and more likely to identify primary specialty. Trainees reported experiencing greater autonomy with subspecialty and outpatient attendings, though this was not necessarily perceived as positive or intentional for their educational or patient care experiences.
Trainee Contributions
Generally, trainees expected significant autonomy in clinical decision-making, but they appreciated attendings who were responsive to their needs for support or guidance. Few trainees described negative experiences with autonomy; most examples of discomfort occurred from perceived overwhelming or inappropriate supervision.
Both groups highlighted trainees’ expressed understanding of their own limitations (humility, communicating uncertainty, and openness to feedback) as a behavior that promoted autonomy. Participants agreed that self-assessment of one’s own comfort level with patient acuity and complexity, utilizing other team members for their expertise and guidance, and being receptive to other perspectives were critical to developing trust and fostered further autonomy.
Additionally, both groups valued a trainee’s ability to articulate their clinical reasoning and prioritize strong communication amongst the patient and provider team. This was particularly reflected in their ability to describe their thought process on rounds, give insightful and accurate feedback to interns and medical students, and proactively and collaboratively communicate with interprofessional team members.
Lastly, team leadership was identified as an important determinant of autonomy for both attendings and trainees. Residents described that their attentiveness to detail often translated to attendings offering more autonomy, and that interns’ attentiveness to task completion often informed their own decisions about autonomy. Attendings mirrored this statement, noting that a resident’s ability to effectively manage the team, pay attention to the details of inpatient care, and capture important details from the EHR were vital to establishing trust.
Patient Contributions
There was almost uniform agreement between trainees and attendings that attending supervision was appropriate in the context of high acuity and complex patients, particularly with co-existing clinical uncertainty. Trainees expressed appreciation and feelings of safety when they knew that attendings would support them and engage in clinical decision-making; attendings acknowledged the opportunity they had to empower resident learning and development, while also ensuring patient safety, in these contexts.
Both trainees and attendings described a generational shift regarding the care of at-risk and under-resourced patient populations. Trainees noted that historically, patients who were affected by social drivers of health or without robust support systems were often those with whom they experienced the most autonomy; attendings reported similar experiences during their own training. However, trainees noted that junior attendings and hospitalists now take on a larger role in the care of these patients. Attendings expressed strong feelings of responsibility and desire to help trainees navigate the complex healthcare system to promote improved outcomes for vulnerable patient populations.
Interestingly, patients with privilege and physician-patients were described as cared for holistically and collaboratively by the medical team, with both trainees and attendings citing patient and family expectations, professional courtesy, and streamlined communication as reasons for adjusting their behavior towards these patients.
Interpersonal Contributions
In addition to any individual team member characteristics or behaviors, the way in which team members interacted and communicated with one another, and how that interaction changed over the course of a shared rotation, was highlighted as a distinct contributor to the autonomy and supervision dynamic. Just as an attending’s practice patterns often informed their approach to the attending role on the inpatient team, trainees had expectations for their own responsibilities. When there was overlap in these roles, strong communication ensured that team members felt valued and supported, rather than hindered and intruded upon. The most frequently described example of this overlap was “task sharing:” when an attending attempted to absorb tasks from the trainee. Attendings described task sharing with trainees when they felt they could be particularly helpful - either because of a specific relationship with a patient and family that had formed, or because of perceived busyness of the trainee - or when they felt that team discontinuity put the attending in a position to fill multiple roles for several days in a row. Trainees had discordant opinions about task sharing; some expressed appreciation for attending willingness to step in, while others found it intrusive on trainee autonomy and growth. However, even with that discordance, both attendings and trainees shared that the impact on team dynamics was improved when expectation setting occurred at the beginning of a rotation and when there was proactive communication about task sharing and roles throughout the rotation.
Both groups identified the benefits and importance of “dynamic supervision” based on the composition of the team that day (accounting for trainee days off). Many attendings described the perceived need to “scale up” supportive efforts during trainee days off, and that these experiences sometimes led them to feel more ownership over patient care than trainees. Trainees, while they acknowledged the attending’s dynamic role, strongly preferred that attendings “scale down” their supervision when the team was whole to allow the resident to assume a team leadership role. Attendings expressed difficulty adjusting levels of supervision when they perceived their role to facilitate continuity for patient care, though residents struggled with their role on the team when attendings did not achieve appropriate dynamism.
Lastly, there were discordant opinions between and amongst both groups over appropriate balance of autonomy and supervision in the context of patients with significant logistical complexity (e.g. multiple consultants contributing to patient care, complicated transitions of care, or previous difficult interactions between a patient and members of the care team). Some trainees and attendings highlighted the benefits of attending involvement in these areas, including their ability to streamline communication between services, navigate a complex healthcare system, and model effective de-escalation and trust-building techniques. Conversely, many communicated concern about attendings and trainees over-prioritizing the ease of having an attending assume responsibility for these fairly common challenges in the inpatient environment at the expense of trainee development.
Institutional Contributions
These complex interpersonal interactions take place within an institutional context that informed the autonomy and supervision dynamic on the inpatient medicine service, specifically the “culture” of the institution and residency expectations for trainees and attendings. Culture was difficult for participants to define but was described as tightly wound with the “hidden curriculum” of an institution and visible within the team dynamic. Both attendings and trainees noted that they mostly learned their roles by shadowing or experiencing them through their own training (if attendings trained at the same institution), thereby perpetuating whatever culture they had experienced previously. Conversely, new attendings described altering their practice in order to assimilate to the perceived values and expectations of their current peers and trainees. This seemed to act as a balancing measure for the impact of an attending’s own training experience.
The residency program’s organizational structure of the inpatient medicine rotation was noted to impact the balance of autonomy and supervision most prominently by contributing to team discontinuity due to call cycles and trainee days off. Both groups acknowledged that many of these changes were necessary to satisfy ACGME requirements and important to promoting trainee well-being. However, they also negatively impacted the functioning of the inpatient team. In fact, many of the issues mentioned above - need for dynamic supervision, changing expectations of roles within teams, and prioritization of continuity for patient care – were attributed to or worsened by team discontinuity. Both attendings and trainees expressed similar dissatisfaction with a team structure that was often fractured.