Psychological Fitness Foundations, Part 6 - Autonomy in Training

We are finally in the last chapter of autonomy as one of three key underpinnings of psychological fitness for physicians – autonomy, relatedness, and competence. This week, I will attempt to tackle – imperfectly so – the unique situation of autonomy for residents and fellows. After all, trainees are not different in what supports their psychological health than attendings.

Autonomy of task/technique (i.e., supervision): Most discussions about autonomy for trainees revolve around the level of independence given while balancing the ACGME/ABFM guidelines, CMS reimbursement rules, and patient safety. So, let’s start with supervision. A recent article, written by Mayo/UCSF experts,  https://onlinelibrary.wiley.com/doi/epdf/10.1111/medu.14580 reviews some sub-optimal types of oversight – from micromanager to absenteeism.

The article recommends a more supportive type of autonomy. The supervisor in this model gives options, information, and rationales behind various options and supports the resident with a partnership that allows choice. They also collaborate on feedback with the learner. And by being more hands-on (as opposed to absent) and offering more autonomy support than a micromanager, the resident’s motivation level is enhanced. Residents with internal or intrinsic motivation have improved engagement, enthusiasm, and self-confidence. That, in turn, improves performance, sustainability, creativity, and a sense of ownership. The article concluded by discussing how a coaching approach offering supportive autonomy shifts the supervisor from being the “gatekeeper of increasing independence” to “a guide…through the developmental process.”

So, what can this look like? My take - Very much like some of us already aim for.  Resident presents patient on two meds for uncontrolled HTN. Wants to increase A. I can support A. I am curious about the decision and listen to their rationale, validating the solid pieces. Then, I explain the pros and cons of B (my usual choice) and C (a third option that others may choose) and why. I may even throw in D and explain the rationale why I wouldn’t support it. I then turn the decision of A, B, or C over to the resident – free of judgment. They get to make their own best decision for their patient. Down the road, if it turns out it did not work, I continue to support the resident that it was a valid choice and explore if this was a fluke or what lessons we can both learn from the outcome. This leads me to want to highlight two important factors in this approach.

Communication: The supervisory portion of autonomy really begins with communication. We know that residents experience more agency when they are involved in the conversation of how support for any given clinical encounter or procedure works best for them. The dialogue is invaluable. “What do you want to get out of the case? Let’s decide who will do which parts? What are the skills on which you are working?” Then, have collaborative feedback at the end. Of course, we want to hit the sweet spot for the resident of the bell curve where it's challenging, and they may experience discomfort for growth, but not so much that they experience stress, fear, or being overwhelmed.

For circs, as an example, we review the goals, roles, and procedural techniques ahead of time. How many they’ve done, when was their last one, and their comfort level. Based on this conversation, we decide if I will be the hands-on assistant and guide, or glove up and stand at the ready while guiding or having them verbalize, or just have my size 6 ½ gloves available while the resident walks through the steps. Then we collaboratively debrief.

Psychological Safety - Reliability/Availability: The attending needs to be reliably and quickly available. The resident needs to reliably involve the attending on higher stakes issues, testing, consults, etc. Having some consensus on which issues, testing, and consults in the context of the complexity and acuity nature of the clinical experience is essential. The resident also needs to know they have full permission to reach out as needed without fear of feeling belittled.

For example, on my best days as an attending (because sometimes I didn’t live up to my own ideal), the resident and I would find collaborative ways to formulate inpatient service plans. The senior decided the plan within the viable options and was also able to support the intern's decisions within patient safety. Then I’d fully support their decision. This also meant I didn't go back and say, "We should have x, y, z" if it didn’t go as planned. I reminded them it was a valid decision with what we knew at the time. And, that still allowed for team reflection of lessons for growth.

After rounds, I found it helpful to set a check-in time in the afternoon to “run the list” so the senior could get support for any issues not already urgently answered before that time. (I personally found a little physical distance – being in the attending room or 10 minutes away in my office – reminded me to keep my natural micromanager tendencies at bay.) Speaking of communication, my system came about after one of my residents (now a program director) was honest enough and felt safe enough to give me constructive feedback. I learned that my texting him each time I found a new issue as I was meeting with patients or chart-stalking inhibited his ability to make it through his checklist in the order he had determined best. (I honestly thought I had been being helpful). After that, the senior and I would agree upon a mutual time to check-in and we each would agree to reach out earlier on more urgent matters.

Ideas for residents/fellows: As a resident, review what’s available to you from your supervisors. Look for what is working and what may need improvement. Where can you communicate, and in what manner, about which types of support push you to grow, which feels restrictive, and which feels unsafe? Ask the individual attending what they need to see you demonstrate, to say, turn the C-section scalpel over to you to primary? What are the opportunities for collaboration and data gathering to begin to shift the system or individuals?

Ideas for programs: As training programs, what areas of communication can be enhanced within the faculty team by involving residents and staff? Are there faculty members who can identify their tendency to micromanage (like me)? Are there some who can identify their belief and tendency to opt for trial-by-fire with a hands-off approach? What support can be given to each to grow their own confidence in a hands-on supportive, collaborative, and coaching manner?

We also must remember communication, reliability, and availability outside of the department. Since family medicine relies heavily on outside attendings – it may be helpful to have an annual discussion between the FM faculty lead for a rotation and the other attendings to develop their engagement in a supportive manner. If they are not academic, updating them on best practices and faculty development tools may be helpful. Inquire about what's working for them and their obstacles to taking this approach. And most of all, remind them of the important role they are playing in the development of many physicians and show them appreciation.

Team: The example of inpatient rounding flows nicely into discussing autonomy of team for residents. The team could be the inpatient team, the clinic staff team, residency/project teams, or others. Again, there is a shared responsibility here. The system would not survive, giving complete independence to each resident's preferences. Patients, staff, co-residents, and attendings would all have whiplash, and many things would likely fall through the cracks. The opportunity to get creative lives here. What parts of running the inpatient team can you turn over to the senior? Perhaps  - Which patients get presented first.  - If rounds need to get bumped back. - If rounds start at the radiology reading room.  - What topic is assigned to individual members to teach, or if they allow the interns to determine their own topic.

In our residency clinic, we had the seniors lead their clinic pod meetings – set the agenda with staff input prior, lead the discussion, and have a real voice in the decisions. Look for places to increase trainee autonomy within the team.

Time: This one feels sticky. But let me venture here anyway. There will be things outside the purview of the trainees, (not unlike the faculty members.) The clinic must have a reliable start and end time. The structure of lunches must be set as well. There are almost 50 part-time providers in our residency clinic, 36 of those are learners. Thus, it would be impossible for schedulers to learn so many individual preferences of appointment lengths. Also to consider is the number of patient-visit standards set by the ACGME. Again, I think we must get creative. I offer a couple of ideas that may or may not work for you, but I bet if you put your faculty and resident collective minds to it, you can uncover untapped areas of time autonomy. Some ideas: -The ability to set certain patients as automatic longer visits. -How and where residents use any admin or care management planning time. -How they set up their long-term-care facility or home visits. -What they do with their time when they’re done with their inpatient care responsibilities for the day (this may also involve the team).

Continue to brainstorm. This will likely also require the program to realize there will probably be a trade-off. You may have to give up a well-intentioned idea of trainees' time. And therein lies the opportunity - to decide which decisions offer a strong enough benefit for the individuals' mental fitness that outweighs what is lost.

Thought work: Residents and fellows, I don’t want to leave you out of the amazing opportunity of reframing and expanding your perspective to ease some of the suffering that can be realized through thought work. There will be many things outside of your control during training and thought work is one of the best ways to cope.

Look for the areas you can appreciate having agency. You likely do have a lot more choice than you're recognizing. If you need more ideas, see my previous suggestions, scroll down to the Thought work sections Here, Here, and Here.  

Next, how is this benefiting you even if it’s not in your choice? In other words, how does this support your ultimate goal of the type of practice you want? There are many ways to view this other than through the reluctant, resistant resident lens, which makes the task feel so much worse. Begin to look at each rotation and requirement through the lens of how it could possibly be FOR you.

Examples:

Default thought - "I am planning on doing outpatient medicine only; this obstetrics rotation does not apply to my life." Rather than argue against the reality that you have to complete the rotation, shift to what you can learn on this rotation that will be helpful. Your brain may offer "nothing" at first pass. But really dig for answers. You'll likely see preconception, pregnant, and post-partum patients in your office, even if unintended. “I’m learning about medications that are safe in pregnancy, warning signs of preeclampsia that a pregnant patient may come into my office for, post-partum complications that I will likely see in my office. The consequences of not thinking of pregnancy loss in women with bleeding. The potential consequences of not checking Rh status and not giving Rhogam. The stark reasons behind preconception counseling. The nature of which a 3rd and 4th-degree laceration can have long-term consequences. I've seen the destruction first hand.” The list goes on.

“Okay, but really this ICU rotation isn’t helpful to my future.” Understanding the communication and systems will benefit you when seeing a patient discharged after experiencing a critical illness. Knowing what families and patients experience in that setting and how that will inform you in your role. I bet you can find ones that feel even more applicable. And if ever you're in doubt, my husband, who completed family medicine before his orthopedic training, still reaps the benefits of his FM training on the regular.

"I have no say in who is on my schedule." Maybe that's true, and maybe there are things you do have control of within your schedule. What are the possibilities? If nothing seems accessible, there are educational opportunities here. Shift your perspective to finding those. What is working about the scheduling system you like? What do you want to take forward into your future practice? How will this part of the education guide you as you check out job opportunities? What things do you know you will want to set up differently?

For every opportunity to complain about lack of control, there is usually a slight shift that will serve you better and lessen unnecessary suffering for yourself. You have to actively look for it. And there is always the option to decide if you have the bandwidth to work within the system for change.

While I'm wading into contentious waters, I will offer an unpopular opinion about residency retreats, fireside chats, and celebration gatherings. I know it feels like a forced use of resident time. And maybe the right thing at any given time (say in a pandemic) in any given residency is to make them optional. And, perhaps, just maybe, it can be viewed as a different type of education. In your future work, the importance of building relationships and engaging the team becomes quite critical to have a robust, stable, and fulfilling practice. You get these 3-5 years to see what works, what doesn’t, what you like, and what you don’t. Because as we will uncover next week, relatedness - a sense of belonging and connection is critical, not only in team relations but in your own personal psychological fitness.

Until then, look for the opportunity inside every difficult situation.

Have a joy-filled week! Tonya

Now is a great time to see how I work with family medicine residency programs to help physicians enjoy their chosen careers. Learn more here.