Autonomy versus supervision for residents is a fine line

When one is a medical student, pretty much everything one does is directly supervised.  Though a student is allowed to assess patients and make recommendations, rarely is a student given the autonomy to make decisions that will affect patients.  They practice these decisions, but there is always someone more senior ratifying them.

Once a student becomes  a resident, things start to change.  As residents are physicians, they have the power to write orders and have them executed without anyone else approving of them.  In the beginning, this is a scary power for the resident, as they are terrified they will hurt someone.  At the same time, it a welcome reward after years of having to ask someone’s permission to do anything at all.

Beyond the ability to just write orders is the idea of resident autonomy.  Autonomy is more than just orders, it is the freedom a resident has to make judgments and act on those judgments without asking someone’s permission.  Autonomy is more complex than just orders, because there are many fewer rules that govern where the edge of autonomy lies, and because over time, that edge moves.   A resident that is very junior may be afforded very little autonomy, but as they become more senior they are expected to take more and more independent authority to make decisions, a transition that is gradually defined not by written rules but in slow changes in the hundreds of interactions with their attending physicians.  In the beginning, a resident could be criticized for being too autonomous, and later in their training, for not being autonomous enough!  They have a difficult job in this regard.

From the outside, some patients may feel that residents should be afforded no autonomy at all.  After all, they are not fully trained, why should they be allowed to execute their decisions without direct supervision?  While this makes sense at some point, it is a misunderstanding of what residency is.  Residency is not being a student doctor.  That’s being a medical student.  Residency is being an apprentice doctor.  Just like the blacksmith’s apprentice that is allowed to forge a sword unsupervised at times, the resident must practice medicine at times without direct supervision.  If residents are never allowed any autonomy, they will graduate board eligible in their field never having made any decisions on their own, making them wholly unprepared for the practice ahead.  If they are given too much autonomy before they are ready, they can be dangerous.

Understanding that too little autonomy can stunt a resident’s development, and too much can potentially lead to significant errors, and attending physician must continuously evaluate each resident and do his or her best to figure out just how much autonomy can be given.  This may very well be the most difficult task an attending physician has.  As the adage says, the residents “needs enough rope to hang themselves, just not enough to hang the patient”.

From a resident’s perspective, this struggle for autonomy takes on a different perspective.  In many cases, it is a mixture of the joy of having the power to commit medicine without asking permission with a sense of fear that one might make a terrible mistake.  The answer to this struggle is always to seek supervision when there is any question of the appropriateness of a particular action.  Residents who are well grounded do this often and are appreciated for it.  Others fail to seek the right amount of supervision when they need it, which frustrates attendings, and through iteration of the supervision process leads to decreased autonomy for a period of time.

The typical path of resident autonomy is that of a sine wave.   Initially, a resident seeks supervision for appropriate issues.  Over time, they find more and more than the plans they propose are being approved.  As confidence grows, supervision is sought less and less.  Eventually, this lack of seeking supervision leads the resident to make an error.  The resident then gets yelled at and feels bad.  Confidence is crushed, and now the residents seeks supervision for every little move for a period of time.  The cycle now starts again.

This cycle is mirrored for the attending physician, who may allow more and more autonomy as a resident demonstrates more and more competence, until one day there is a problem, initiating a short period of yelling or other expression of consternation, followed by a period of decreased resident autonomy.  While increased resident autonomy may relieve the attending of some physical work, it also comes at the cost of increased vigilance, as one needs to expend great energy to make sure that things are going well even while allowing others to make decisions with less supervision.

And this is the nature of things, and it has worked for a long time in training to residents become autonomous physicians.

And so now we come to the yelling -

When residents make mistakes, sometimes they get yelled at.  In truth, it is usually more of verbal dressing down, but ‘being yelled at’ is common vernacular for any manner of such treatment.  Some residents complain about this, feeling that they are being treated badly, or are being unnecessarily made to feed bad or have hurt feelings.  And to this I have this to say -

Suck it up.   Residents have a choice to make, and that choice is between autonomy and supervision.  Any resident can completely eliminate any possibility of being yelled at by seeking supervision for anything they do.  While this is a fairy miserable way to train, at least no attending will be justified in taking them to task.  On the other hand, a resident can choose to do some things without asking permission, which after a certain amount of training is a far more satisfying (and efficient) way to go through residency.  BUT – any resident that chooses to do this (and almost all do), MUST accept that with this freedom comes the possibility that they may get taken to task for a mistake.  This is the price of their freedom.

But is it too much to ask that attending physician just always be nice and provide perfectly constructive criticism and never really get mad?  Yes is is.   Supervising residents is an emotionally taxing task.  The attending physician is ultimately responsible for everything the residents do, and in turn all of the medical care delivered under their supervision.  Attendings know that allowing resident autonomy will occasionally lead to an error, but to not allow it is to squelch resident growth, and create a job that is physically impossible to accomplish.  But what about the patients?  Does allowing this resident autonomy endanger them?   As long as it is done right, it does not.  Because there are so many checks and balances in the system, it is very difficult for any one person to make a mistake that injures a patient.  Medical errors that injure patients usually involve many people, not just one.   So giving the residents some rope is OK.  But it is stressful, and when residents make mistakes, they have to be redirected, and sometimes attendings aren’t super nice about it.

So to all the residents out there that are reading this, give your attendings a break.  The autonomy they give you is a gift that is difficult to give.  Choose to accept that gift, and you have to accept the criticisms that may come with it.  If you can’t take it, you can always choose to ask permission for everything.  But if you really want to learn, and to enjoy your residency, just grow some skin and get out there and do it.

Nicholas Fogelson is an obstetrician-gynecologist who blogs at Academic OB/GYN, where this article originally appeared.

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  • alex

    Nobody seems very up in arms that PAs and NPs can write orders (unsupervised in some states) after half the schooling of a medical student, so the fuss over residents amuses me.

  • http://www.MDWhistleblower.blogspot.com Michael Kirsch, M.D.

    I recall as a medical student in NYC, students who were choosing residency programs where they could ‘run the cases themselves’. This seemed odd to me then, and still does. Why would an intern and resident want to avoid supervision when it is most needed? I chose a program where I was tightly supervised and grateful for it. I knew I would have decades afterwards to run my own cases. Ironically, there are many times now where I wish a senior physician was around the corner.

    • Bobbo

      Makes sense to me. People want the hands on experience, not sitting and watching. Perhaps if you went to a place where you were less tightly supervised, you wouldn’t find yourself wishing to have a senior watching over your shoulder all the time.

      As the author points out, however, there is a balance between learning and making mistakes. Naturally residents will flock to the program that gives them the greatest experience and ability to learn.

  • http://www.MDWhistleblower.blogspot.com Michael Kirsch, M.D.

    @Bobbo, is there any practicing physician who wouldn’t want a mentor or senior clinician around from time to time? I hope not, or I would wonder about that practitioner. Rx tincture of humility. Regarding last statement of your comment, can be difficult for a med student to gauge a training program in advance for its ability to maximize the educational experience.

  • Trent

    “Naturally residents will flock to the program that gives them the greatest experience and ability to learn.”

    You can always volunteer for service in Afghanistan. You’ll learn in 2 years what it would take 10 years here. And you won’t have to worry about being sued for malpractice.

  • Martin Young

    My experience was this: heavily supervised during the day, when seniors were at work, and ‘do what you like’ at night and after-hours. So the level of autonomy depended on the seniors’ availability!

  • http://dign.eu Pieter Kubben

    I am a 5th year resident in neurosurgery, and recognize the issues described here. I also feel that more and more I want to decide on my own, as there will remain controversies on specific issues. When I do have a preference and good reasons for a strategy, I am glad to take the responsibility. And indeed, it is good to get used to it before you start as a staff member.

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