Introduction

During clinical training residents are gradually afforded autonomy in medical decision making and patient care responsibilities. Supervising faculty must balance nurturing trainee independence with appropriate care provision, efficiency, and patient expectations.^1–3 Recent studies have suggested that provision of autonomy is an area of concern for faculty and residents.^4,5 Trainees express that they are not given enough opportunities to participate in clinical decision making, while faculty identify the challenges of supporting autonomy for residents in settings of high acuity, high patient census, and limited trainee experience.⁶

Family-centered rounds (FCR), defined as interdisciplinary bedside rounds where the “patient and family share in the control of the management plans,”⁷ have become a widely adopted model for rounds in the pediatric setting.⁸ FCR provide supervising physicians the opportunity to directly observe trainees interacting with patients and families.⁹ This is an important educational benefit, as it can help physicians make informed assessments about their trainees' readiness for independent practice.^10–12 Multiple studies have described effective teaching practices used by bedside teachers,^13–15 including 1 study that assessed FCR.¹⁶ However, there is a lack of studies to guide attending physicians toward how to promote resident autonomy during FCR.¹⁷

We designed a qualitative study of residents, hospitalists, and subspecialty attending physicians to discover general teaching strategies used by attending physicians, including those that promote resident autonomy during FCR. Our study describes strategies aimed at promoting resident autonomy, and is 1 facet of a larger study of general teaching behaviors.

Methods

We conducted a qualitative study from December 2012 to February 2013 at Children's National Health System in Washington, DC. Using constructivist methodology, an approach that is designed to help people explain and make sense of their experiences,¹⁸ we sought to build an understanding of our participants' perspectives concerning autonomy during FCR.

Results

Fourteen residents participated in 2 resident focus groups. The first focus group consisted of 8 PGY-1s, and the second focus group consisted of 6 PGY-2s and PGY-3s. Ten attending physicians participated. Six were hospitalist attending physicians, and 4 were subspecialty attending physicians. The participating attending physicians were predominantly assistant professors, with an average of 7 (range 3.5–12) years of academic experience.

The analysis of transcripts revealed numerous teaching strategies that promote autonomy during FCR, as self-identified by attending physicians and as perceived by residents. These strategies were grouped into 13 themes, and then organized into 4 categories based on timing that emerged through the analysis: (1) at the start of the rotation; (2) prior to FCR; (3) during FCR; and (4) following FCR (after all patients are rounded on). A summary of the themes and strategies that we identified, which promote autonomy within the context of FCR, is presented in table 1. Accompanying illustrative quotations are detailed in table 2.

table 1 Strategies to Promote Autonomy on Family-Centered Rounds (FCR) Compiled From Attending Interviews and Resident Focus Groups

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table 2 Illustrative Quotations of Residents, Hospitalists, and Subspecialty Attending Physicians Regarding Autonomy on Family-Centered Rounds (FCR)

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Discussion

Attending physicians and residents held similar views on how to best foster trainee autonomy. Qualitative analysis revealed 4 distinct time periods during which attending physicians actively promoted resident autonomy: at the start of the rotation, before, during, and following FCR.

Deciding when to share the teaching and leadership responsibilities during rounds is a complicated task and has been compared metaphorically to a dance, wherein attending physicians have to balance “standing back” and allowing the PGY-2/PGY-3 to “step up.”²⁴ Based on a needs assessment, Wipf et al²⁵ established an annual 6-hour resident teaching course, which included a variety of topics including managing an inpatient ward team. Comparison of their case-based curriculum with our study revealed similarities. For example, they suggested that PGY-2s/PGY-3s meet with the attending physician at the start of the rotation to discuss goals. Another similarity involved the importance of having the PGY-2/PGY-3 pick, at the beginning of rounds, which patients should be discussed in more detail and which patients should be examined at the bedside.

To our knowledge, there is only 1 other article that specifically focuses on promoting PGY-2/PGY-3 autonomy during FCR: Weisgerber et al¹⁷ have described the development of a 21-item FCR checklist to offer residents feedback on their rounds performance. The checklist included strategies consistent with the suggestions of our participants such as avoidance of “micromanaging,” delegating teaching responsibilities to the PGY-2/PGY-3, encouraging trainees to answer family's questions first, and having the attending physician stand in a nondominant position.

While our study identified behaviors that promoted autonomy during FCR, many of the strategies identified in our study were not specific to FCR, and are applicable to traditional bedside rounding as well. For example, our participants suggested effective general teaching strategies that are well documented in the literature such as the importance of giving feedback²⁶ and the use of reflection.²⁷ Since our results overlap with many general strategies for successful bedside rounding, institutions that are considering transitioning to FCR may find the process less difficult than initially considered.

Of note, 6 of the 10 inpatient attending physicians chosen by the residents in our study as excellent educators were hospitalists. This is of interest as prior studies have suggested that the use of pediatrics hospitalists compared to general primary care pediatricians may reduce resident autonomy.^28,29 As hospitalist programs are growing,³⁰ and hospitalists are taking on larger teaching roles, it is important for them to have a framework that promotes supervising trainees in a manner that encourages their professional development.

This study has several limitations. It was conducted at a single institution with a small number of participants, and the findings may not be transferrable to other settings. Recruiting residents through e-mail may have introduced selection bias. The vast majority of the resident physician quotations were derived from the PGY-2/PGY-3 focus group rather than the PGY-1 focus group. Finally, it is possible that the roles of 3 of the 4 investigators as regular participants in FCR may have introduced bias into the interpretation of the data despite the aforementioned methods to ensure trustworthiness.

Further research is needed to confirm our identified strategies for promoting autonomy during FCR. New studies should also focus on whether the implementation of these strategies improves patient and family satisfaction, resident evaluations of their attending physicians, and trainee satisfaction with FCR.

Conclusion

Our results offer multiple strategies for attending physicians to promote autonomy and empower their residents in the context of FCR. The findings of our study may contribute to faculty development efforts aimed at improving the educational value of FCR for all participants.