P4A094: Balance Between Supervision and Autonomy During In-patient Rounds: The Residents’ Perspectives

Background: A balance between progressive resident autonomy and supervision leading to independent practice without compromising patient care is an important component of resident education and professional development. However, there is a lack of studies on the residents’ perspective on autonomy and supervision pertaining to inpatient rounds. The objective of this study was to evaluate the perspective of residents on their level of autonomy as well as associated barriers during inpatient rounds at a large academic children’s hospital.

Methods: Using REDCap, we surveyed pediatric residents at 3 different levels of training about their perception of autonomy and supervision in respect to their experience on the inpatient wards at a high-volume children’s hospital. Rounds typically include a senior resident (either 2nd year (PL-2) or 3rd year (PL-3)), two 1st year interns (PL-1s) and two medical students as well as the attending hospitalist. Survey responses were recorded using 5 response options – never, occasionally, sometimes, frequently, always.

Results: The survey was distributed towards the end of the academic year. Of a total of 81 residents at various levels, 91% responded. Of 74 respondents, 95% agreed that there is a gradual increase in their responsibilities based on the level of training, and 81% agreed that autonomy and supervision are balanced. PL-1s were less likely to agree to “be involved in giving feedback to more junior trainees” (p=0.039), “not being interrupted by the attending physicians” (p=0.043), and “being included in making teaching points during rounds” (p=0.036), see figure 1. Interestingly, about half of the senior residents reported that they lead rounds as an “attending”. When given answer choices about the barriers to senior led rounds, 83.3% chose “high patient volume and not enough time”, and 95.8% chose “senior residents have too many other responsibilities during rounds”. Upon review of the 34 free text responses about barriers, 3 main themes emerged: 47% reported the number of “additional senior responsibilities during rounds prevented them from leading rounds effectively”, 21% chose “resident’s comfort level in their role or lack of a clearly defined role”, and 18% chose “time constraints”.

Conclusion: Our pilot study shows that although almost all senior residents agreed that they were comfortable with making management plans, they faced barriers in leading rounds as an “attending” in a busy inpatient setting. Future quality improvement projects should focus on interventions to address barriers such as time limitation and the many responsibilities of senior residents when leading rounds without compromising education and patient care. Additionally, expectations around senior led rounds may differ at the resident, attending and program leadership level which was not captured by our data and may warrant further investigation.