Trainee Autonomy and Supervision in the Inpatient Clinical Learning Environment

Background: Balancing autonomy and supervision during medical residency is important for trainee development while ensuring patient safety. In the increasingly complex inpatient clinical learning environment, tension exists when this balance is skewed. In this study, we aimed to understand current and ideal states of autonomy and supervision and then describe factors that contribute to imbalance from both trainee and attending perspectives.

Methods: A sequential mixed-methods design included surveys and focus groups of trainees and attendings at three institutionally affiliated hospitals between May 2019 and June 2020. Survey responses were compared using t-tests, chi-square tests or Fisher's exact tests. Open-ended survey and focus group data were analysed using thematic analysis.

Findings: Survey response rate was 42% (76/182) for trainees and 49% (101/208) for attendings. Fourteen trainees and 32 attendings participated in 14 focus groups. Trainees perceived current culture to be significantly more autonomous than attendings; both groups described 'ideal' culture as more autonomous than current state. Focus group analysis revealed five core contributors to the balance of autonomy and supervision: attending, trainee, patient, interpersonal and institutional. These factors were found to be complex and interactive and require frequent adjustment to avoid tension.

Conclusions: Trainees and attendings agree that resident autonomy should be prioritized more than it currently is. Attendings, trainees and patients contribute to a complex dynamic between autonomy and supervision, further impacted by both interpersonal and institutional factors, in the inpatient clinical learning environment. Capturing complex interactions between individual factors that impact this dynamic is critical to understanding and optimization by both trainees and attending.