How Can Residents Learn To Think On Their Own? Qualitative Studies Of Cognitive Autonomy In Residents

Autonomy: Everyone agrees that resident autonomy is important but, in contrast to resident procedural autonomy, there are no validated measures of resident cognitive autonomy. Two recent qualitative studies shed some light on the issue. Crockett et al conducted focus groups and open-ended surveys with residents in 6 mostly-cognitive specialties, asking them to define autonomy and to specify what attending physician actions promote or undermine autonomy. Santen et al conducted focus groups with both residents and attendings in emergency medicine, getting their perspectives on entrustment and autonomy. In this latter study, four factors were felt to materially influence the level of autonomy granted to a resident by the attending physician: patient factors (medical acuity and social complexity), resident factors (level of training and perception of resident quality), systems factors (busyness and the local culture of resident autonomy), and faculty factors. The authors report a strong influence of “faculty personality and approach”, with attendings ranging from “micromanagers” to “ghosts”. In the multi-specialty study, residents said they recognized receipt of autonomy when: they made independent decisions, they took a visible role as team leader with patients and others, and they received more trust over time. Residents in these specialties had very similar ideas about attending behaviors that promoted or impaired autonomy. The authors summarize: “Challenging residents to support their care plan while remaining supportive of their thought process is critical, as is basing any changes from the resident plan on evidence rather than style. Being available at a distance as a ‘safety net’ is important for the comfort level of resident physicians, but allowing time to work in the absence of the attending physician is also important for autonomous activity.” Maybe the micro-managers and ghosts among us can try harder to display these behaviors. — Laura Willett, MD

Crockett C, Joshi C, Rosenbaum M, Suneja M. Learning to drive: resident physicians’ perceptions of how attending physicians promote and undermine autonomy. BMC Med Educ. 2019 Jul 31;19(1):293.
Link To Article
Santen SA Wolff MS, Saxon K, Juneja N, Bassin B. Factors Affecting Entrustment and Autonomy in Emergency Medicine: “How much rope do I give them?”, West J Emerg Med. 2019 Jan;20(1):58-63.
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Autonomy is a complicated concept to residents; it tends to be highly desired, yet simultaneously feared. A fresh July intern initially fears autonomy due to lack of experience, but as they grow into autonomy-craving residents, a residual fear of complete independence remains. Thus, these two recent qualitative studies did not yield surprising results. Crockett et al, in which focus groups and surveys were used to determine behaviors of attending physicians that support or undermine autonomy, found that residents reported autonomy to be critical to their development as independent physicians. This desired sense of autonomy was supported by attendings who allowed residents to take the lead with an appropriate level of supervision. This essentially describes the “perfect” attending. Every resident fears the extremes: the attending who hovers all hours of the day, commenting on everything from choosing enalapril over lisinopril to improper comma use in a progress note, versus the attending who leaves the hospital at noon and seemingly never has cell phone service. The highly desired attending falls right in the middle, allowing the resident to independently interview, assess, plan, and manage the patient with minimal intervention unless care of the patient is compromised, while maintaining a level of support and accessibility. Similarly, Santen et al used resident and faculty focus groups to discuss entrustment of residents and found that multiple factors affected entrustment including patient factors (acuity, socioeconomic issues), environmental factors (patient volume, systems), resident factors (year of training, previous experience with resident), and faculty factors (confidence level, education interest, fear of risk). These findings again highlight an important point; certainly residents need to be driven and competent enough to seek out their own autonomy, but the attending behind them must possess the confidence and experience to allow the resident to independently make their own assessments and decisions, assuming these decisions will not have a negative impact on patient care. From the perspective of a senior resident, having a supportive attending is comforting, but the attending must remember we will soon be “in the wild” without supervision.  — Lauren Pioppo, MD (PGY 3)

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