Promoting clinical autonomy in medical learners

Micromanagement in clinical supervision: a scoping review

Micromanagement in clinical supervision in health professions education generally refers to supervision characterized by unproductive excessive control and attention to detail. It can affect autonomy, competence, well-being of learners, teamwork, and ultimately patient care. Despite its potential negative impact on learners and patients, no comprehensive review of this phenomenon has been conducted. This scoping review aims to explore the breadth of extant literature concerning micromanagement in clinical supervision in health professions education and map the body of research on the topic. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis: Extension for Scoping Review (PRISMA-ScR). We searched eight databases, and the final review and analysis comprised 12 articles that examined micromanagement in clinical supervision across health professions education. Micromanagement was conceptualized as ineffective supervisory practices such as undue scrutiny, excessive control, domination, and ineffectual leadership. Conversely, alternatives to micromanagement included entrusting or granting autonomy, coaching for independent practice, and providing effective supervision and leadership. Overall, micromanagement was attributed to individual behavioral and personality factors, such as distrust, perfectionism, self-conviction, and low self-esteem. The consequences of micromanagement included inadequacies in professional development and well-being of trainees and patient care, and organizational dysfunction. Suggested solutions included entrusting or empowering trainees with encouragement and clear communication, open communication efforts by trainees, organizational management for quality supervision, and faculty's valuing both clinical and educational goals. Current literature on micromanagement-in the context of clinical supervision in health professions education-was found to be sparse, implying a need for more rigorous research and discourse on this understudied area. The findings can be used to recognize, solve, and prevent the prevalent, and often unrecognized, phenomena of micromanagement, which may improve clinical supervision, the professional development of trainees and faculty, organizational management, and ultimately patient care.

Micromanagement During Clinical Supervision: Solutions to the Challenges

Learner autonomy is an invaluable asset in graduate medical education, preparing the trainee to independently face challenges in the future professional settings. Educational institutions face the difficult task of providing a balance between learner autonomy and supervision. In graduate medical education, trainees often prefer less supervision than what is imparted by their attending physician. This increased supervision comes at the cost of learner autonomy and has not exhibited improvement in patient outcomes or safety. When attendings exhibit control over details, the trainees may label them as “micromanagers”. Cardinal features of a micromanager include excessively requesting updates, insisting that the task be done their way, and scrutinizing every detail. This micromanaging behavior is non-conducive to the learning environment and may even contribute to supervisor burnout. The business literature reveals a debate about this very topic. Unfortunately, there is still a lack of literature on micromanagement in graduate medical education.

Although a conglomerate of internal factors may lead to excessive supervision in an academic medical institution, we surmise that micromanagement exists because of a complex dynamic between three drivers: accountability, trust, and autonomy. When trainees are held accountable, they learn to take ownership for their actions which leads to establishment of trust which further enables motivation and gaining of autonomy. Supervising attendings should ideally be able to comfortably adjust their level of supervision based on their trust and the trainee’s competence, accountability, and autonomy. The micromanaging physician is unable to do so, and this can have a detrimental effect on the learner.

Micromanagement can be perceived by some as a beneficial component during the early immersion of the trainee with the rationalization for better patient outcomes and safety. However, in the long term, it threatens the learning environment and erodes the complex relationship between accountability, trust, and autonomy. We recommend an action plan to mitigate micromanagement at three levels-the micromanager, the micromanaged, and the organizational structure-and hope that these solutions enhance the learning environment for both the trainee and supervisor.

Autonomy and developing physicians: Reimagining supervision using self-determination theory

In this article, we address the question, 'What is the role of autonomy in physician development?' Medical education is a developmental process, and autonomy plays a motivational role in physician development. Calls for increased supervision of residents have raised concerns that the resulting decreased autonomy might interfere with resident development, leading the authors to explore the relationship between supervision and autonomy. The medical education literature posits a simple inverse relationship between supervision and autonomy. Within competency frameworks, autonomy is operationalised as independence and viewed as the end goal of training. Alternatively, there is emerging empirical literature describing autonomy and supervision as dynamic and developmental constructs and point towards more complex relationship between supervision and autonomy. Self-determination theory (SDT) presents a framework for understanding this dynamic relationship and the role of autonomy in physician development. Within SDT, autonomy is a fundamental psychological need, associated with motivation for learning, self-regulation and an internal locus of control. Supporting learner autonomy can afford learners the opportunity to internalise the values and norms of the profession, leading to an integrated regulation of their behaviours and actions. Conceptualising autonomy through the lens of SDT provides an avenue for education interventions and future research on supervision and autonomy. Educators can integrate supervision and autonomy support in the clinical setting, seeking to motivate learner development by balancing optimal challenge and support and integrating autonomy support with 'hands-on' approaches to supervision. SDT also provides a theoretical framework relevant to current discussions regarding feedback conversations and coaching in medical education. Lastly, conceptualising autonomy using SDT opens new avenues for investigation, exploring the complex relationship between supervision and autonomy and developing efforts to integrate autonomy support with clinical supervision.

Goldilocks and Entrustment: Finding the Amount of Learner Autonomy That's Just Right

INTRODUCTION

Faculty and residents strive for appropriate autonomy and entrustment. Initial direct supervision of clinical care gradually shifts to increasing levels of resident independence over time. Faculty members are inconsistent in resident supervision leading to missed opportunities for resident independence.

METHODS

Family medicine faculty workshop participants completed teaching style self-evaluations prior to discussion of clinical examples with excessive or insufficient autonomy. Participants reviewed real resident feedback examples to increase insight into teaching styles. Participants were presented with cases to discuss varying degrees of resident autonomy and entrustment. Learners committed to one specific behavior to calibrate the degree of autonomy they provide.

RESULTS

Of the faculty, 113 members participated in the workshop with the majority (98%) finding the workshop relevant in helping them to identify strategies for reflecting on their degree of autonomy allowed and to look for appropriate situations for enhancing their resident entrustment.

DISCUSSION

This interactive workshop provided clear ways for addressing the issue of independence versus control in supervision of patient care. It provided a feedback mechanism for educators who provide too much or too little autonomy for the best resident learning. Additionally, this conversation encouraged participants to engage in self-reflection on the autonomy given to their resident.