Teaching Prescription Pad: Learner Autonomy
Session recorded October 18, 2021

Welcome to this session of the Teaching Prescription Pad, where we learn the prescription for effective teaching from the best clinical teachers, this session is on learner autonomy. Our expert is Dr. Gena Benoit. Dr. Benoit is a 1999 graduate of the UI Carver College of Medicine. She trained in family medicine at Genesis in Davenport, Iowa. She has been a faculty member for 15 years in the residency program and recently assumed the position of residency program director. Her entire career has revolved around medical education. I am Jeff Pettit, your moderator. Welcome, Dr. Benoit.

Thanks, Jeff. Thanks for having me.

My first question is, why is this topic important or of interest to you?

Well, after being involved in medical education for such a long time, I have seen a lot of changes in how we deliver that medical education, specifically how things have been affected by the evolution of duty, our requirements and levels of supervision in medical training. And I had thought back to when I was a medical student and a new resident and what the model looked like at that time and how it has changed until now.

You know, when many of us were training years ago, we were in this kind of apprenticeship model and there was sort of a hierarchy with medical students and residents and sometimes fellows. It was all supervised by an attending physician that may or may not be with you most of the time that you were doing your work. It was kind of this model where everyone got this graded responsibility. So, you got to do more and more as time went on and a lot of the time we were not necessarily supervised. People like to reflect back on stories of the good old days when we each had these experiences in the middle of the night. Maybe when we were having to handle something by ourselves or a patient who was crashing or something exciting and all that we learned from that experience when we were kind of forced into those situations.

But I learned that that model of medical education sort of came into question with the death of a young woman named Libby Zion. Many have heard of her. But for those who have not, it is a really interesting story to read about. She was a young lady who was sick and admitted to a hospital and ultimately died. An after her death, it was alleged by her father that the residents who had been caring for her were overworked and they were overseeing too many patients. They were tired and maybe they really did not have the supervision that some thought they needed. At that time, though, her case really brought into question kind of that model of medical education. Did we need more supervision of our residents? Should we not be allowing them to work so many hours that it could put patient safety into question? So that whole model was challenged and that is sort of the impetus for the changes in duty hours and levels of supervision. I thought that was a really interesting story. To kind of understand the origins of that was pretty fascinating.

But the model that we are working with today, even though those changes were made, we have not seen maybe the outcomes that everyone was looking for there. There have been some modest increases in the amount of sleep that residents get when we restrict working hours. But we have not really shown a lot of changes in errors or changes in patient outcomes. But what we did see is that residents are working less hours and they have more supervision. But on the flipside of that, sometimes more supervision leads to less autonomy. So, residents are not getting to do things on their own or maybe have those middle of the night experiences. That led to some questions like, how well trained are our learners these days, and how can we do better to provide that kind of autonomy in this sort of newer form of medical education?

I was trying to think about myself as a learner and as a teacher and I can recognize the struggles on both sides. I think learners really want to do things. We have all been in that situation, whether it is years ago or now, when someone just wants you to shadow them, or they promise that you will get to do the next procedure that is coming up and you start to glove up and get ready. And then your teacher kind of nudges you out of the way at the last second. We get that learners want those hands-on experiences, and they want to be able to do things, just as many of us did. When I became more of a teacher, I could see the other side of it and say, “you know, these are my own patients now, and I kind of feel possessive of them.” How do I let go of some of that control and let these learners do things and get that experience? It was kind of that whole reflection, I guess, of looking at the changes in medical education over time. That is kind of what got me here.

In researching this topic and thinking about it, I realized that most of the best learning experiences that I had really involved me getting to do things and have that opportunity. But I had a safety net. I think that is what most people want these days. They want that autonomy, and they want to do things, but they still need and want some version of a safety net. I really liked it when I was able to see the patient or interview and examine them and come up with a differential or talk about what I thought for a plan or even do a procedure. But there was always someone there, someone to discuss that with and teach me about it and guide me through it. And I was not necessarily alone in the times that I thought were really great learning experiences. So really, where this all came from was kind of processing all of that and trying to find what is the balance that we can provide of autonomy with supervision to provide a really great learning experience.

You kind of touched on it, in your explanation. What is the difference between autonomy and supervision? Where is the balance? Where is the fine line between them?

When you look at just dictionary definitions of autonomy and supervision, that is what we tend to think of now. You can really put them at two ends of a spectrum. You think of autonomy as just acting independently; the learner is doing things on their own. You could think of supervision as that teacher having complete control. But we really do not want to think that way. It does not have to be so black and white, or it does not have to be two ends of a continuum or a spectrum. Trying to find that balance in the middle, I think, is what we are going for. We do have data that backs this up. There have been a number of studies looking at how increased levels of supervision can affect the learner’s autonomy and the learner’s experience. A lot of these were done in ICU settings with changes in medical education over time. An Intensivist was put in the ICU to supervise twenty-four seven. The students and the resident learners were not really ever alone at all.

What those studies have shown is that learners and often teachers have a negative perception of how this experience goes. They feel like it was not a positive thing on either side of it. The worrisome thing is that they often feel unprepared. Those who have been in training feel that that intensive supervision has led them to feel unprepared. Even though we kind of think about those possible definitions as extremes, we want to kind of soften them a little bit, and we want to think of autonomy in a little different way. I guess what autonomy means to learners is kind of how I would like to spin it or like to define it. So rather than doing things all by yourself, learners perceive autonomy as they have been given meaningful work. You have given them something to do that is not gut work or kind of being pushed to the side or to stand in the corner and watch me. They have been given something meaningful to do. That does not mean they have to do something all by themselves or they run the whole visit. It can be something small, but it has to be meaningful.

The other things that kind of define autonomy for learners is they prefer not to be micromanaged. I think all of us like that from our bosses, our supervisors, and our teachers. That is an important part. They also defined autonomy as being given clear communication. You can explain what you want from them or what you are going to expect them to do. Clear communication just helps in every situation, not exclusively this. Another thing that they felt reflects autonomy is being given more than one chance to do something. Whether that is answering a question incorrectly the first time or maybe you asked them to freeze that wart and they did not quite do it strong enough. Well, explain it to them. Give them some of that clear communication and let them try it again. Maybe the first patient that they saw with you that day, they did not present it in the way you wanted. Give them another opportunity; everybody likes a second chance of things.

Other things that learners felt kind of provided autonomy was us recognizing that there is more than one way to do things. If it does not affect patient safety or if it is not clearly wrong, sometimes allow their ideas to be considered, even if it is not exactly what you would do. Maybe you are seeing a patient with high blood pressure. If there are no other contra indicators or indications—maybe you like Lisinopril and they are suggesting Amlodipine—if there is no reason that they cannot take it, maybe let them prevail or acknowledge that that is a good idea. I like this one, but that is just my practice style. Giving them a little something where maybe their idea is a valid one, you can let them win in a way. Their meaningful work is not being micromanaged, being clearly communicated with, given more than one chance, and acknowledging there is more than one way to do things, that is how learners would like to define autonomy and they would also like it with a safety net. That is where the supervision comes into play.

We can define supervision as more like a watchful observation—that you are guiding someone, you are watching and observing them. It does not mean that you have to be doing it yourself. These two ends of the spectrum of complete autonomy, complete supervision, it really does not have to be defined that way. Knowing the things that I just mentioned, learners would like to be somewhere in the middle. If teachers could go a little more to the middle as well, that would help, because I think they are saying these are the things I would like. They are not saying leave me alone—leave me alone in the room to try to figure this out. They would like all of that, but they still want you there. As a supervisor, do you have to be present and watch and observe the whole interaction? What is the amount of involvement? I am sure it depends also on the level of experience of the learner as well.

There are different levels of supervision. Some of it is mandated by organizations like the ACGME. Sometimes it is determined by your own program or the place that you are learning. We all, of course, follow the ACGME recommendations and their levels of direct supervision where the instructor, the teacher, whoever that may be, is physically present with the learner. There is indirect supervision where you are available to them, either by phone or on the same campus. There are definitely different levels to that. As long as you are working within those official guidelines, beyond that, it is a little bit up to you how you want to do it.

One of the things that I hear often is that we do not know what they know. We are not sure how much autonomy to give a learner. It is different if it is a resident that you work with on a daily basis all the time. If I get a medical student who is only going to spend a few 1/2 days with me (sometimes it is only one-half day), I have never met them before, maybe I do not know where they are at, that leads a little bit to a struggle sometimes. But it does not mean that you cannot adjust the autonomy you give them, even in that short experience. Maybe they go see the first patient with you and they see what you are doing. With the second patient, you let them take a history and you let it evolve. Some of this involves matching the level of autonomy with the level of the learner. It doesn't mean that every M-2 gets to do a full HSP and a procedure in one visit. They may just do a history. They would be very satisfied with that because to them, that is meaningful work that matches the level that they are at and that would be great autonomy to provide for them. If it is a resident that I am with on labor and delivery and then a third-year resident managing their own continuity patient, I am going to let them do a lot more and be more hands on. So, you have to kind of structure it in a way that it matches. That is not always obvious at the beginning of your interaction. 

How do you determine to what degree and what level you allow autonomy to the learner?

That is one of the biggest challenges. Some of it, I think, is being aware of where they are in their training. This whole process can probably be accomplished in just a few minutes, sometimes even chatting with them just to give you a place to start. 

If you have good communications when you first meet this learner and understand where they are, maybe what rotations they have been on prior to coming to you, what is their background like, what are their interest areas and other things that they are looking for, sometimes interest areas are not necessary. “Well, I am just interested in skin or hemorrhoids or whatever it is.” It is more what are you wanting to work on. You want to work on your presentation? Do you want to work on your assessments and plans or coming up with the differential? Where are you now in your training? What have you done that has led you here? What would you kind of like to get out of your time with me? I can be pretty short and that can give you a place to start. Like I mentioned earlier, sometimes the verbal interaction gives you some information, but you kind of need to see them do it, too. This does not mean that you have to just set them off and send them alone to the first experience. It is okay to observe or kind of tag team with them. I think most learners do not mind that as they are getting oriented to you in your clinic or your hospital rounds, whatever it is, but then gradually give them some more autonomy as you go would be very much appreciated. So even though maybe brief, if you can think of giving a little progression about autonomy during a short a short period, that would be helpful.

In a situation where you have given the learner quite a bit of autonomy and then realized maybe you have gone too far in that continuum; how do you regroup or pull back to kind of gain and start over again?

Well, part of being good at giving autonomy, you know, one of the tips that we say is providing constructive feedback and also a formal assessment, but at the time, some constructive feedback. If you have given someone a little too much and then need to pull in the reins, I think as long as you communicate that clearly with them and give them feedback on how that interaction went and what went well and what did not, you can kind of start a new baseline. Maybe if in seeing the patient, they did not take a complete history—they came out and presented it to you and it is full of holes and missing information that you need. That really slows you down and kind of affects your patient care for the day. If you regroup with them and give them honest feedback about that situation and you just have a new starting point—maybe say that history was really not enough, so maybe come in and watch me take a history with the next patient—then kind of show them. Or maybe I will go with you the next time and observe, and I will give you some cues for the things that were missing. If it was a deficit in their assessment and plan—you have let them come up with the assessment and plan and they are lacking in something—then maybe while you go see the next patient, have them go look up the treatment for hydrogen, nitrous or whatever it is that they just saw with you and then pull them back. You do not have to cut them off from that autonomy just because they have made a mistake. Or maybe they did not fulfill what you thought. You can always slow them down a little bit, but then hope to ramp back up again. 

Are there other challenges or issues to consider with the degree and level of autonomy that you give the learner?

In talking with other teachers at all different levels, a couple of challenges I mentioned already involve duty hours and supervision. I think as far as feeling some constraints from that at the level of the ACGME or sometimes there are constraints at your system level. The thing that most people mentioned is a challenge—no one is surprised to hear me say this—but it is time. You do not have enough time in the day to work with someone to be able to give them a good experience, give them that autonomy. Sometimes it is limited time with the learner. As I mentioned before, maybe you are only working with that learner for a really short period, and you are not sure you can kind of go down that autonomy spectrum like I was just discussing.

Personal personalities and styles certainly come to play. We always joke that a lot of us in medicine tend to be type A personalities—needed to get straight A’s and needed to have some perfection that kind of got people to where they are—they needed those traits to succeed. But sometimes that makes us a little controlling and not wanting to give up some of that to the learner. Personality styles definitely can add some challenges. I mentioned before the challenge of not knowing what they know. The more you are engaged with them—the medical school that you are working with or your partners—and the more you just kind of know about the learners that you are getting, that can be helpful. And like anything, the more you do it, you see more over time. You gain more experience, and you can recognize things in your learners that they may or may not need. But for those in private practice—you are trying to meet quality metrics—sometimes if you have a medical student who is performing the visit, they may not be hitting all the bullet points that you need to hit for your quality, which affects your pay. There are financial challenges to this as well for our volunteer preceptors and teachers. So, there is a lot.

But in looking at it as far as trying to overcome those things, I think if we sort of take it in small bites, this does not mean you have to totally change everything that you are doing. Or if you have a medical student with you for the day that they need to run your whole clinic. Give them small amounts of that meaningful work and that autonomy. It does not have to be they do not have to be involved in every second of everything that you do. But a small amount can go a long way.

You have given us a lot of great information, just to kind of sum up here. Do you have any advice or suggestions for someone to have and work with the concept of autonomy?

Yeah, I think, you know, my first piece of advice and it is something I try to keep at the forefront when I am working with learners is to, I guess, remember where you came from a little bit. Remember the experiences that you got in the past and whether they were positive or negative. Think about the kind of training that you got, the things that were good and that were great learning experiences. Even though medical education may be different now or it may be a different scenario than what you had tried to provide that same experience to your learners, remember what has what worked well for you and then try to emulate that just now on the other side. On the teaching side. So that's one thing.

A couple of things that I really liked in the research that I did. One, of course, was communication. I think good communication is the key to everything. But that is one part of this. The two other things that I really love. One was the advice to provide the optimal challenge, and that is about kind of meeting your learner where they are at and being able to provide them the autonomy that they need. I kind of mentioned earlier, you know, if you have an M-2 spending a half day with you, you are not going to probably send them in to see the patient completely alone or do a procedure by themselves at the beginning. But they can certainly start by taking a history and presenting it to you. So, try to match what you are asking with their level and sort of provide the optimal challenge to your learner. It is not always easy to tease out what that is. It takes a little bit of effort, but the more you do it, the better you will get at it.

Then the other thing that I really liked was just these simple statements that to me kind of show that you are empowering them, and you are asking them to take ownership of the situation, but you are there to help them. All you need to say is this is your case. I will be right here if you need me. I thought that really sums up that I am giving this to you, I am giving you this ownership, and I want you to get autonomy out of this experience. But I am here, and that does not mean I am micromanaging you, but I am here for you. So, this is your case. I will be right here if you need me. 

This has been really good information related to autonomy, and we want to thank Dr. Benoit for her information.

For additional information, if you have questions or would like follow-up information, you are welcome to use the email address you see on the screen: OCRME-PrescriptPad@uiowa.edu. I will respond and get the information back to you as soon as I can.

We will also have all of the interviews on our website: https://medicine.uiowa.edu/ocrme/teaching-prescription-pad. Along with each interview, there will also be a podcast that can be downloaded and a transcript of each of the presentations. So, again, thank you, Dr. Benoit, for your time being with us. And we hope that you will be a future teacher and some other topics of interest. For the audience, thank you for joining us and I hope you see some of our other interviews in the future.