Fellows journal Club
Article: Moriarty J, Vellanki S, Trope LA, Hilgenberg SL, Blankenburg RL. Righting the Autonomy-Supervision Pendulum: Understanding the Impact of Independent Rounds on Medical Students, Residents, and Faculty. Acad Med. 2020;95(11S), S28-S36. doi: 10.1097/ACM.0000000000003645.
Fellow: Eleanor Sharp MD, Second-Year Fellow in Pediatric Hospital Medicine, UPMC Children’s Hospital of Pittsburgh
Summary: Balancing adequate supervision of pediatric trainees with the development of trainee autonomy is challenging. Faculty supervision provides an additional layer of patient oversight while also offering opportunities for teaching and feedback. Meanwhile, supporting trainee autonomy leads to increased internal motivation and the development of independent practice. In the past decade, the balance has tilted towards increased trainee oversight, which has resulted in decreased clinical decision-making autonomy and fewer opportunities for trainees to practice supervisory skills. This study sought to return some of that autonomy to pediatric trainees through independent rounds led by senior residents without the physical presence of an attending. Dr. Moriarty and her collaborators implemented their independent rounding intervention at two unique study sites and performed focus groups to examine the impact of independent rounding on medical students, pediatric interns and residents, and pediatric faculty members.
Strength: This is the first qualitative exploration of how an independent rounding intervention impacts trainee autonomy, medical student teaching, and faculty experience. The study included the perspectives of the entire educational continuum, from medical students to faculty. The authors performed thematic analysis using the constant comparative approach associated with grounded theory, which means that they started with the data (i.e., focus groups) and then developed theories based on the data. In grounded theory, the data, analysis, and theories are constantly interacting, as the researcher creates meaning of the data through systematic analysis and eventually the development of themes. This method provided rich qualitative data from the perspectives of various levels of learners.
Limitations: Given the qualitative methodology of this article, patient outcome metrics such as medication error rates, length of stay, time of discharge, or frequency of readmission were not analyzed. Additionally, while the study took place at two unique sites, the residents at both sites were from the same residency training program, which may limit generalizability. Finally, the study did not investigate the perspectives of nurses, respiratory therapists, patient care technicians, consulting services, etc., and these care team members may be impacted by independent rounding. Most importantly, while it was outside the scope of this study, the effect of independent rounding on the experience of patients and families remains unknown.
Major Takeaway: While we may be reluctant to let our trainees drive, this study suggests that handing over the keys can increase trainee internal motivation, patient ownership, and overall wellness without sacrificing patient safety. Senior residents noted that they found themselves embracing a leadership role even on non-independent rounding days, and junior trainees saw their senior colleagues as positive near-peer role models. Medical students reported that independent rounding created a more relaxed learning environment with less pressure to perform and therefore the ability to focus on learning. Interestingly, faculty members reported that not being present on rounds led to a change in identity, a decreased sense of relatedness to the team, and decreased overall career satisfaction. Despite this, the authors noted that the impact of independent rounding on resident development was so positive, faculty decided to expand the practice to additional ward teams.
How this article should impact our practice: Implementation of independent rounding may be an effective way to teach our trainees novel skills—even in our absence.“If increased supervision leads to a more passive roles for trainees, fewer opportunities to make decisions, and a reduced sense of personal responsibility for patients’ welfare, greater supervision today could reduce the quality of the physician workforce tomorrow.” - Kerlin & Halpern, 2012 May;141(5):1315-1320.
Fellow: Eleanor Sharp MD, Second-Year Fellow in Pediatric Hospital Medicine, UPMC Children’s Hospital of Pittsburgh
Summary: Balancing adequate supervision of pediatric trainees with the development of trainee autonomy is challenging. Faculty supervision provides an additional layer of patient oversight while also offering opportunities for teaching and feedback. Meanwhile, supporting trainee autonomy leads to increased internal motivation and the development of independent practice. In the past decade, the balance has tilted towards increased trainee oversight, which has resulted in decreased clinical decision-making autonomy and fewer opportunities for trainees to practice supervisory skills. This study sought to return some of that autonomy to pediatric trainees through independent rounds led by senior residents without the physical presence of an attending. Dr. Moriarty and her collaborators implemented their independent rounding intervention at two unique study sites and performed focus groups to examine the impact of independent rounding on medical students, pediatric interns and residents, and pediatric faculty members.
Strength: This is the first qualitative exploration of how an independent rounding intervention impacts trainee autonomy, medical student teaching, and faculty experience. The study included the perspectives of the entire educational continuum, from medical students to faculty. The authors performed thematic analysis using the constant comparative approach associated with grounded theory, which means that they started with the data (i.e., focus groups) and then developed theories based on the data. In grounded theory, the data, analysis, and theories are constantly interacting, as the researcher creates meaning of the data through systematic analysis and eventually the development of themes. This method provided rich qualitative data from the perspectives of various levels of learners.
Limitations: Given the qualitative methodology of this article, patient outcome metrics such as medication error rates, length of stay, time of discharge, or frequency of readmission were not analyzed. Additionally, while the study took place at two unique sites, the residents at both sites were from the same residency training program, which may limit generalizability. Finally, the study did not investigate the perspectives of nurses, respiratory therapists, patient care technicians, consulting services, etc., and these care team members may be impacted by independent rounding. Most importantly, while it was outside the scope of this study, the effect of independent rounding on the experience of patients and families remains unknown.
Major Takeaway: While we may be reluctant to let our trainees drive, this study suggests that handing over the keys can increase trainee internal motivation, patient ownership, and overall wellness without sacrificing patient safety. Senior residents noted that they found themselves embracing a leadership role even on non-independent rounding days, and junior trainees saw their senior colleagues as positive near-peer role models. Medical students reported that independent rounding created a more relaxed learning environment with less pressure to perform and therefore the ability to focus on learning. Interestingly, faculty members reported that not being present on rounds led to a change in identity, a decreased sense of relatedness to the team, and decreased overall career satisfaction. Despite this, the authors noted that the impact of independent rounding on resident development was so positive, faculty decided to expand the practice to additional ward teams.
How this article should impact our practice: Implementation of independent rounding may be an effective way to teach our trainees novel skills—even in our absence.“If increased supervision leads to a more passive roles for trainees, fewer opportunities to make decisions, and a reduced sense of personal responsibility for patients’ welfare, greater supervision today could reduce the quality of the physician workforce tomorrow.” - Kerlin & Halpern, 2012 May;141(5):1315-1320.
Fellow: Eleanor Sharp MD, Second-Year Fellow in Pediatric Hospital Medicine, UPMC Children’s Hospital of Pittsburgh
Current Research: I’ve been fortunate to have opportunities to pursue multiple scholarly projects while also obtaining my Masters in Medical Education during fellowship. I am passionate about curriculum development and assessment and developed a Critical Care De-Escalation Curriculum for pediatric trainees. The content of this curriculum was informed by the results of another project I’m leading in which we are using the PHIS database to identify patients at highest risk of PICU readmission. Additionally, the issue of gender equity in academic medicine has motivated me to perform two different survey-based needs assessments of faculty and trainees at my institution. Based on these results, my next project will be a national, multicenter study of trainee parents’ experiences with pregnancy, parental leave, childcare, and breastfeeding.
Future Plans: I will graduate from fellowship in June 2022 at which time I will be starting my first faculty position in Pediatric Hospital Medicine. I am an educational scholar and my goal is to earn a leadership role in an educational program, specifically that of fellowship director. I’m looking forward to a career in Pediatric Hospital Medicine and a lifetime of (hopefully in-person…) PHM Conferences!
Fun Fact: I have been skydiving three times and went snorkeling with great white sharks in South Africa, but I am terrified of butterflies!
Current Research: I’ve been fortunate to have opportunities to pursue multiple scholarly projects while also obtaining my Masters in Medical Education during fellowship. I am passionate about curriculum development and assessment and developed a Critical Care De-Escalation Curriculum for pediatric trainees. The content of this curriculum was informed by the results of another project I’m leading in which we are using the PHIS database to identify patients at highest risk of PICU readmission. Additionally, the issue of gender equity in academic medicine has motivated me to perform two different survey-based needs assessments of faculty and trainees at my institution. Based on these results, my next project will be a national, multicenter study of trainee parents’ experiences with pregnancy, parental leave, childcare, and breastfeeding.
Future Plans: I will graduate from fellowship in June 2022 at which time I will be starting my first faculty position in Pediatric Hospital Medicine. I am an educational scholar and my goal is to earn a leadership role in an educational program, specifically that of fellowship director. I’m looking forward to a career in Pediatric Hospital Medicine and a lifetime of (hopefully in-person…) PHM Conferences!
Fun Fact: I have been skydiving three times and went snorkeling with great white sharks in South Africa, but I am terrified of butterflies!
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