Background: The relationship between autonomy and supervision (A/S) on general medicine inpatient services requires a balance to ensure patient safety while fostering graduated competency in residents. Previous research at our institution has shown a tension hospitalists feel when balancing these two principles. For example, hospitalists reported that the ideal clinical culture should offer more autonomy to residents, but the environment in which they currently practice reflects more supervision. In order to better understand the clinical learning environment, we surveyed internal medicine residents in the same institution to explore their perspectives.

Methods: We created a 19-item web-based survey for residents of a large internal medicine residency who rotate at three inpatient sites, including a quaternary referral center, an academic safety-net hospital, and a Veterans Affairs (VA) hospital. Questions included perception of the current and ideal culture of A/S, six unique clinical vignettes that assessed attending behaviors on a scale of “directly supervisory” to “complete resident autonomy”, and free text responses eliciting residents’ perspectives of, and suggested changes to, the current culture. We used descriptive statistics to summarize quantitative survey responses and content analysis to elucidate themes from free text comments. Resident responses were compared to attending responses for the same questions from a separate attending survey.

Results: Forty-two percent of residents (76/182) completed the survey. On a scale of “entirely autonomous (0)” to “entirely supervised (1)”, they rated the culture at each training site. Mean scores were: 0.42 (0.50) (quaternary referral center); 0.15 (0.36) (academic safety-net hospital), and 0.18 (0.39) (VA hospital). In contrast, residents rated their ideal training culture with a mean score of 0.11 (0.32). There was a statistically significant difference between the current and ideal culture at the quaternary referral center (p < 0.001). These results along with comparison to attending survey data are shown in Table 1. Brief descriptions of the six clinical vignettes and participant responses are shown in Table 2.

Conclusions: Our survey demonstrates that residents align with attendings in favoring a more autonomous culture over supervisory culture, though they prefer a higher degree of autonomy than attendings. Residents perceive the current learning environment as more autonomous when compared to attendings’ perceptions at all three of our inpatient sites, suggesting differences in how residents and attendings evaluate these two topics. The majority of vignette responses favor more resident autonomy, but trend towards more supervision during changes in acuity. In cases where attending and resident responses differ, attendings prefer more supervision than residents. This study highlights ongoing tension felt by both residents and attendings when balancing A/S and demonstrates the need for further studies to understand an ideal balance to optimize the clinical learning environment.

IMAGE 1: Table 1: Residents’ Perceptions of Current vs. Ideal Cultures by Site and by Comparison to Attendings’ Perceptions

IMAGE 2: Table 2. Clinical Vignettes with Associated Median Attending and Resident Responses.