62 - Finding (and keeping) a voice amidst complex systems and increased supervision: residents’ perceptions of clinical decision-making and patient care ownership
Clinical Fellow University of California, San Francisco, School of Medicine University of California San Francisco San Francisco, California, United States
Background: Concerns about patient safety have spurred calls for increased supervision of residents. This may inhibit their autonomy and impede a sense of ownership of patient care. Intrinsic motivation for learning may diminish and growth into independently practicing physicians may be compromised. Factors that contribute to residents’ perceptions of autonomy and the connection to decision-making and motivation to learn are incompletely understood. Examining this further may augment the professional growth of residents despite conditions of increased supervision in the current learning environment.
Objective: This study explored relationships between residents’ opportunities to make clinical decisions and their feelings of ownership over patient care with autonomy and learning.
Design/Methods: We recruited 38 residents from 3 pediatric programs for semi-structured interviews using critical incident technique and explored experiences related to remembered moments of decision-making. We analyzed data through an iterative, inductive process in which 2 investigators coded interview transcripts to generate themes. We used DedooseTM software for analysis. Institutional review boards approved this study.
Results: We identified 3 major themes:
1) Decision-making opportunities can be diminished by a) learning environment (culture, subspecialist involvement), b) patient factors (complexity, acuity), c) resident factors (seniority, knowledge, confidence). 2) Sense of ownership is most affected by a) relationship with patients and families, b) inclusion in decision-making. 3) Cultivation of purpose is attributed to a) relationships with families, team and supervisor, b) finding and holding a voice.
Residents described ownership as being viewed as the doctor taking care of the patient, regardless of who made decisions. The degree of ownership felt by residents varied by institution. Conclusion(s): The ability for residents to feel ownership over patients' clinical care is essential for professional development, yet several factors outside residents' control affect their ability to do so including institutional culture and patient complexity. Lessons learned by this study can help shift the focus from supervision and autonomy as diametrically opposed conditions to creation of learning environments that promote resident participation in a team context. Ultimately, this may better support resident development of a sense of patient care ownership and meaning in work.
Authors/Institutions: Margaret Robinson, University of California San Francisco, San Francisco, California, United States; Judith Bowen, Washington State University Elson S Floyd College of Medicine, Pullman, Washington, United States; Megan Aylor, Oregon Health & Science University, Portland, Oregon, United States; Sandrijn VanSchaik, University of California San Francisco, San Francisco, California, United States
