How can pediatric hospital medicine (PHM) fellowships best support their fellows to become autonomous practitioners? Key stakeholders in the relatively nascent PHM fellowship training process face the conundrum of balancing autonomy while maintaining adequate safety and supervision. As PHM fellows are more advanced trainees than residents, their needs and perceptions will be unique from those of residents. Accreditation Council for Graduate Medical Education (ACGME) program requirements for PHM fellowship indicate the importance of promoting progressive autonomy and flexibility.1 Prior studies have evaluated the factors that influence faculty and their promotion of resident and fellow autonomy.2-3 However, there are a relative dearth of studies examining PHM fellow perception of their own autonomy.
In this issue of Hospital Pediatrics, Jurgens et al. performed a longitudinal qualitative study involving semi-structured interviews with 14 fellows who started their fellowship in July 2021 (10.1542/hpeds.2024-007855). Four interviews with each participant were conducted over their fellowships and were coded and clustered into themes. Four key themes were identified. Importantly, it was found that perceptions of autonomy are dynamic and change throughout the training process.
The first theme found that fellows generally valued more direct supervision at the beginning of fellowship, and this was not perceived as a detriment to autonomy. This begs the question—is autonomy only related to direct versus indirect supervision? Or is it also freedom to safely make clinical decisions that are different than what the attending might do?4 The second theme was relevant to this—many fellows felt pressured to make the exact same clinical decision as their attendings; however, this belief changed with time and recognition that multiple clinicians may approach the same clinical scenario slightly differently. The element of choice is perceived to be vital. As hospitalists we know there is a gray area in practicing medicine and seeing the consequences of one’s medical decisions is imperative to developing confidence and experience as a clinician. Thirdly, the value of the attending role evolved as fellowship progressed, from more direct supervision to that of a coach for formative feedback. For indirect supervision, an example solution involved attendings following along after team rounds and collecting data from families and staff regarding how patient encounters were going. Lastly, it was identified that the hierarchical nature of medicine can sometimes hinder conversations about autonomy. We know the small size of PHM programs makes anonymity difficult, especially for fellows hoping to hire on at the same institution they trained at. This is an important point for all program leadership to consider.
This paper contributes to a growing body of evidence regarding trainee supervision. As PHM continues to develop as a specialty, fellow and faculty perceptions will influence policies regarding safe autonomous practice. This article is a good read for anyone with a vested interest in shaping the future of our pediatric hospital medicine workforce.
References
- ACGME Program Requirements for Graduate Medical Education in Pediatric Hospital Medicine. ACGME. Updated 2022. Accessed June 24, 2024. https://www.acgme.org/globalassets/pfassets/programrequirements/334_pediatrichospitalmedicine_2022v2.pdf.
- Maniscalco J, Davis E, Gay AC, et al. Factors and Behaviors Related to the Promotion of Pediatric Hospital Medicine Fellow Autonomy: A Qualitative Study of Faculty. Academic Pediatrics. 2019;19(6):703-711. doi:10.1016/j.acap.2019.05.003
- Hauer KE, Oza SK, Kogan JR, et al. How clinical supervisors develop trust in their trainees: a qualitative study. Medical Education. 2015;49(8):783-795. doi:10.1111/medu.12745
- Conner SM, Choi N, Fuller J, et al. Trainee Autonomy and Supervision in the Modern Clinical Learning Environment: A Mixed-Methods Study of Faculty and Trainee Perspectives. Preprint. Res Sq. 2023;3.rs-2982838. Published 2023 Jun 6. doi:10.21203/rs.3.rs-2982838/v1
