PHM 2025 Session Recap
Improving resident autonomy on inpatient wards remains a hot topic across the country. In particular, the recent Accreditation Council on Graduate Medical Education (ACGME) requirements for pediatric residency training have pushed inpatient physicians to consider how to optimize autonomy even when residents may be spending less time on inpatient hospital medicine services. This session explored evidence-based approaches to fostering entrustment and autonomy and strategies to address potential barriers to autonomy in the inpatient setting. Although framed in the context of the ACGME changes to pediatric training requirements, the concepts are broadly applicable to adult hospitalists working with trainees as well.
The presenters (Karen Allen, MD, Rena Kasick, MD, and Alana Painter, MD) began by defining autonomy. Though sometimes conflated with independence, trainee autonomy is fundamentally different—it refers to the internal desire to drive one’s own behavior. Autonomy involves assuming responsibility, decision making, troubleshooting, and recognizing the impact of decisions. When successfully supported, it reinforces motivation and satisfaction. However, autonomy is not granted all at once; it requires a process known as “scaffolding”. In this approach, faculty provide close support early on and gradually reduce it as competence grows. As faculty support decreases, trainee responsibility increases. This process requires continuous assessment of the learner’s abilities and may span over a few days or the course of an entire training program.
Promoting autonomy is critical. It strengthens clinical decision-making and allows for the necessary practice of skills prior to independent practice. It fosters ownership of patient care and encourages critical thinking and engagement. It also enhances internal motivation and well-being among trainees. Despite importance, systemic barriers may hinder the cultivation of autonomy. These include heightened emphasis on patient safety leading to increased faculty oversight, rising patient complexity, work hour limits, and expectations for attending involvement from patients, families, and hospital staff.
So, how can hospitalists support trainee autonomy? The presenters highlighted several key concepts. First, set the expectation that the resident is the team leader. This expectation should be set from the start, communicated clearly during rounds, and continually reinforced. Expectations to discuss ahead of time may include preferred communication methods, reasons to escalate concerns, and who will lead educational efforts. Establishing clear roles, providing regular bi-directional feedback, and maintaining open communication are also essential. Trainees should be given opportunities to make independent clinical decisions, supported by regular feedback from the attending.
The SREA-21 (Senior Resident Empowerment Actions) tool, developed by Weisgerber et al (2011), was introduced as a method to assess and support resident autonomy. It includes the “Four Ss”:
- Silence – attending should empower residents to speak first and wait until they are finished to add input.
- (be) Second – attending should physically and verbally take a supporting role, for instance, physically occupying a non-dominant position, entering the room after the senior resident, and letting them lead the discussion.
- Secret Moves—attending should set residents up for success through pre-planned support, such as planning rounding logistics or teaching points together ahead of time.
- Safety—maintain psychological safety with affirming feedback and public validation, using gentle corrections when necessary.
Another strategy is independent (or senior-led) rounding, where the senior resident leads rounds without the attending present. This promotes independent decision-making and builds ownership and leadership. A typical model involves a pre-rounds huddle to identify suitable patients for independent rounding and review care plans. While the resident leads rounds, the attending “shadow rounds” separately, maintaining open lines of communication during that time. Post-rounds, the resident and attending meet to review finalized plans and address issues. The presenters shared that, in their experience, independent rounding has led to more efficient rounds and increased attending satisfaction due to more direct patient care. However, they noted that it may make providing medical student feedback more difficult.
Despite these tools, barriers to autonomy persist. These include a lack of confidence among attendings and trainees, high service demands, nursing and family expectations, large or rotating teams, and efficiency concerns. Learner-specific challenges also exist. Some early trainees need more support, while other trainees may lack confidence or insight into their limitations. In all cases, scaffolding and regular, honest feedback should be used to gradually build capacity for autonomy.
Navigating autonomy becomes more complex in teams with fellows. To manage this, teams should have a clear hierarchy with stepwise escalation in communication, well-defined roles, and mutual understanding of who leads clinical decisions. Fellows should be encouraged to observe, step back, and allow residents to practice clinical reasoning – intervening only when necessary. This approach also builds fellows’ entrustment skills, which are vital to their own professional development.
The session concluded with a few more practical tips. Attendings should move away from an “all-or-nothing” approach to autonomy; if residents are given autonomy on certain aspects of patient care or with a subset of the patients, there is still great value. Additional practical pearls include redirecting questions to the residents, establishing non-verbal cues with the senior resident for support, and validating resident plans even when they differ stylistically from those of the attending. Creating a culture that values teaching and gradual entrustment allows trainees to build confidence and competence.
As residency curricula evolve, the need for structured scaffolding and intentional autonomy-building strategies will be increasingly important. Faculty must adapt to ensure all learners develop into confident, capable, and autonomous physicians.
Key Takeaways:
- Supporting trainee autonomy is critical for clinical skill development, critical thinking, and patient ownership, and fosters internal motivation and well-being.
- Autonomy is a gradual process, requiring intentional scaffolding, ongoing assessment and feedback, and deliberate strategies to promote responsibility and decision-making.
- Specific strategies include: intentional expectation setting and reinforcement of senior resident or fellow as team leader, the Four Ss tool to guide behavioral adjustments for faculty, senior-led rounding, and clear and open lines of communication for bi-directional feedback.
Dr. Norton
Dr. Norton is an assistant professor of pediatrics and an associate program director of the pediatric residency program at the University of Michigan Medical School in Ann Arbor.
Dr. Jacobson
Dr. Jacobson is an assistant professor of internal medicine and pediatrics and associate program director of the pediatric hospital medicine fellowship program at the University of Michigan Medical School in Ann Arbor.