Promoting Resident Autonomy – PediaCast CME 106

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Description

Drs Rena Kasick and Karen Allen visit the studio as we consider resident autonomy. The educational journey to become a pediatrician takes 11-14 years. An important milestone along the way is transitioning from supervised to autonomous practice. This is a long but important process, one that strives to develop competent physicians while keeping patients safe and improving medical and educational outcomes. We hope you can join us!

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1. Read this information page.
2. Listen to the podcast.
3. Complete the post-test at Nationwide Children’s CloudCME.

This episode is approved for FD-ED credit through the Center for Faculty Development at Nationwide Children’s Hospital. CME and FD-ED credit expires 3 years from this episode’s release date.

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Topics

Resident Autonomy
Pediatric Resident Training

Presenters

Dr Mike Patrick
PediaCast and PediaCast CME
Nationwide Children’s Hospital

Dr Rena Kasick
Associate Program Director, Pediatric Residency
Pediatric Hospital Medicine
Nationwide Children’s Hospital

Dr Karen Allen
Pediatric Hospital Medicine
Nationwide Children’s Hospital

Learning Objectives

At the end of this activity, participants should be able to:

1. Understand the importance of resident autonomy in pediatric training programs.
2. Identify strategies to effectively transition residents from supervised to autonomous practice.
3. Recognize the challenges and barriers to resident autonomy.
   Explore the impact of resident autonomy on patient care and educational outcomes.

Links

Pediatric Residency Training Program at Nationwide Children’s Hospital
The Autonomy Toolbox: A Multicenter Collaborative to Promote Resident Autonomy
Autonomy Is Desired, Entrustment Is What Matters
Pediatric Residency Program at Ochsner Hospital for Children
Community Pediatrics Training Program at Columbia University
Coaching Program at Stanford Pediatric Residency

Disclosure Statement

No one in a position to control content has any relationships with commercial interests.

Commercial Support

Nationwide Children’s has not received any commercial support for this activity.

CME/CE Information

In support of improving patient care, Nationwide Children’s Hospital is jointly accredited by the American Nurses Credentialing Center (ANCC), the Accreditation Council for Pharmacy Education (ACPE), and the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for the healthcare team. (1.0 ANCC contact hours; 1.0 ACPE hours; 1.0 CME hours)

Nationwide Children's Hospital has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 1.0 AAPA Category 1 CME credits. Approval is valid for 2 years from the date of the activity. PAs should only claim credit commensurate with the extent of their participation.

As a Jointly Accredited Organization, Nationwide Children's Hospital is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. Nationwide Children's Hospital maintains responsibility for this course. Social workers completing this course receive 1.0 continuing education credits.

Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs.

Contact Us

CMEOffice@nationwidechildrens.org

 

Episode Transcript

[Dr Mike Patrick]
This episode of PediaCast CME is brought to you by Hospital Pediatrics and the Pediatric Residency Training Program at Nationwide Children's Hospital. 

Hello, everyone, and welcome once again to PediaCast CME, we are a continuing medical education podcast for healthcare providers. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio. It's episode 106. We're calling this one Promoting Resident Autonomy.

I want to welcome all of you to PediaCast CME. So, pediatricians are not made in a day. In fact, we have a very long training process that we go through.

After we graduate from high school, we have to spend four years as a pre-med undergraduate student, so we get our bachelor's degree. Then we go on to medical school, which is another four years. In pediatrics, pediatric residency is another three years.

And then if folks want to do a subspecialty, so let's say you want to become a pediatric cardiologist, or a pulmonologist, or an emergency medicine doctor, then you have to do a fellowship, and that is typically another three years.

So, we're really talking about close to 15 years of post-high school education in order to practice pediatric medicine, and up toward 15 years is really those pediatric subspecialists, and sometimes even longer. Here's the thing, after medical school, students graduate and become doctors, but it's really during residency that one goes from being a student doctor with lots of supervision to being an autonomous physician who is ready to practice medicine without guardrails in place, and that is a really important process. In the past, this was just supposed to happen.

There wasn't necessarily an intentional process to promote and nurture autonomy in a safe and effective way, but that has really changed in recent years, and in fact, last year, actually it was in 2023, so we're just over a year now, an article was published in the journal Hospital Medicine called the Autonomy Toolbox, a multi-center collaborative to promote resident autonomy, and today we are fortunate to have the lead and senior authors of this paper on the podcast, Dr. Rena Kasick, she is a pediatric hospital medicine physician and associate program director for our pediatric residency training program here at Nationwide Children's. Dr. Karen Allen is also, she's actually the lead author, and she is also a pediatric hospital medicine physician here at Nationwide Children's. So, they're going to join us soon.

First, I do want to remind you that after listening to this episode, be sure to claim your free Category 1 CME credit. Really easy to do, just head over to the show notes for this episode at pdacastcme.org. You'll find a link to the post-test in the show notes.

Follow that link to Cloud CME, click on the materials tab, take and pass the post-test, and the Category 1 credit is yours. We offer credit to many pediatric professionals, including doctors, nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists. And since Nationwide Children's is jointly accredited by many professional organizations, it's likely we offer the exact credits you need to fulfill your state's continuing medical education requirements.

Of course, you want to be sure the content of this episode matches your scope of practice. And if you work with residents who are in training programs in any capacity, then this really is in your scope of practice. So, if you're a clinical pharmacist, you have a role to play in the autonomy journey of pediatric residents and residents in other specialties as well.

So, this really is a good one for everyone, especially if you practice in academic medicine and you have trainees in your area. By the way, complete details on the continuing medical education credit is available at pdacastcme.org. Also, I want to remind you the information presented in every episode of our podcast is for general educational purposes only.

We do not diagnose medical conditions or formulate treatment plans for specific individuals. Your use of this audio program is subject to the PediaCast CME Terms of Use Agreement, which you can find at pdacastcme.org. So, let's take a quick break.

We'll get Dr. Rena Kasick and Dr. Karen Allen settled into the studio, and then we will be back to explore resident autonomy. It's coming up right after this. 

Dr. Rena Kasick is an Associate Program Director with the Pediatric Residency Training Program at Nationwide Children's Hospital. She also practices pediatric hospital medicine and is an Assistant Professor of Pediatrics at The Ohio State University College of Medicine. Dr. Karen Allen is also a pediatric hospitalist at Nationwide Children's and an Assistant Professor of Pediatrics at Ohio State. Both have a passion for guiding and supporting pediatric residents on their journey toward autonomy.

In fact, they are the first and senior authors of a paper published in Hospital Pediatrics last year entitled The Autonomy Toolbox, a Multi-Center Collaborative to Promote Resident Autonomy. But before we dive into this important topic, let's offer a warm PediaCast welcome to our guests, Dr. Rena Kasick and Dr. Karen Allen. Thank you both so much for being here today.

[Dr Rena Kasick]
Thanks for having us.

[Dr Karen Allen]
Happy to be here. Thank you.

[Dr Mike Patrick]
Yeah, absolutely. We're really happy that you guys are here too. Rena, I wanted to start with you.

What exactly do we mean by resident autonomy? And why is that important in pediatric training programs?

[Dr Rena Kasick]
Yeah, that is a great question. So, autonomy, the root definition of that is the desire to be one's own origin of behavior. So, in residency training, when young doctors in training are learning how to practice medicine, autonomy essentially is the opportunity or ability for resident physicians to put the information and data they've gathered to formulate a working diagnosis for the patient and then enact the plan of care that they put out and developed for them.

So of course, in a training environment, this would be with the appropriate supervision from fellows and faculty. We know that resident autonomy encourages greater ownership of patients, fosters really good clinical competence in a supervised setting, and is important preparation for independent practice. So, it's kind of akin to learning how to ride a bike.

They need to actually put their feet on the pedals and pedal so they know what it feels like and then calibrate their movements in a safe setting with the training wheels on or someone nearby to catch them so that they can learn how to do it on their own.

[Dr Mike Patrick]
Yeah, and so when medical students graduate from medical school, they're doctors, but they are definitely green and a little wet behind the ears. And so they need lots of supervision in the beginning, but as you travel through those years of residency, you want for them by the end to really be able to see folks on their own, getting histories and physicals, coming up with a differential diagnosis, a workup plan, and then once we have the diagnosis, a treatment plan, and doing all of that independently. And so there has to be some milestones to get from point A to point B.

Karen, what are some of the key milestones in residents' transition from completely supervised to autonomous practice?

[Dr Karen Allen]
Yeah, that's a great question. And our ACGME, the governing body for residency training, has some milestones that they expect all of our residents to hit before they reach graduation and are completed with their training. And some of those are in the realm of patient care, some are like communication related, some are quality improvement related.

They don't really outline exactly how to get there, just more that we expect them to reach that by the end of graduation. So, we like to think of autonomy more as a spectrum than necessarily having discrete steps. And each resident may reach those at different times in their training.

Like an intern may be able to practice some autonomy by talking directly to families or advocating for a certain plan on rounds, whereas a more senior resident is probably going to be able to actually enact a plan with less supervision than an intern might have. So, we expect that an early senior resident may even have the ability to order fluids on their own or choose an antibiotic on their own, whereas someone who's about to graduate may be more ready to make more complex decisions like patient coordination planning or discharge planning. So really, it's up to us as faculty to kind of meet residents where they are and assess them at the beginning of our time with them to kind of determine where they are in their autonomy journey.

[Dr Mike Patrick]
Yeah. And what does that assessment look like, Rina, in terms of from at the program level? So, I'm sure that there's a lot of data points that go into determining when a particular resident is ready, because it's not just like, well, during the first year, you should do this.

Second year, this other thing. Third year, a different thing. Especially if each resident is kind of traveling at their own rate, how do we know when residents are ready?

What sort of data are you looking at?

[Dr Rena Kasick]
Yeah. So as pediatric residency training programs actually move more towards competency-based assessments and incorporate the use of entrustable professional activities or EPAs, I think we'll have more clarity and granularity for teaching faculty in particular to know when to entrust or give our pediatric residents a little bit more autonomy. I think when we think about how we can do it in real time, essentially resident trainees, while on their clinical rotation, demonstrates what they know, their clinical reasoning and their skills.

And when they present that on rounds, then we as faculty kind of acknowledge that that's happening in real time and can determine whether or not it's appropriate. And based on that, our faculty provide further scaffolding to help advance the learner's knowledge and skills. And if they demonstrate that they understand what's going on with the patient and have sound clinical reasoning, the attending allows the resident more autonomy or more opportunities for autonomous decision-making.

So, as you can see, it's a bit subjective when we think about the clinical environment in situ, but with each new rotation, the learner may have to show the attending what they know before they're granted more opportunities. Many programs, including ours, use milestones or other competency frameworks, which can tell us, for example, how well a resident performs a physical exam or communicates with patients and their families, but it gives only a small snapshot on a resident's performance. So, as we incorporate entrustable professional activities or EPAs, that's what we call them, or everyday pediatrician activities, is what the ABP calls it, it underscores the mastery of these essential tasks and skills in order to deliver appropriate patient care.

And when we map our residents against these EPAs, I think we can all understand their performance level a little bit better and allow for greater autonomy. So long answer short in some ways, like we just have to understand how they perform in order to provide more opportunities for autonomous medical decision-making.

[Dr Mike Patrick]
Yeah, yeah. And I think that individual attendings who are working with residents, and as you say, and it's sort of a shame that a resident has to sort of prove themselves with a new attending, but there's no way around that. However, I think attendings can make that job a little bit easier if you go into the rotation and thinking, how can I increase this particular resident's autonomy rather than how can this resident help me get my work done?

And so, by having that conversation and sitting down with a resident at the beginning of a rotation to say, what kind of things have you done in this particular specialty? And what do you feel comfortable with? What do you hope to learn?

And then you can really get a little bit of a better idea of where an individual resident is on their autonomy journey by having that conversation ahead of time rather than just okay, we're working together as a team. I would imagine that you kind of see that in some attendings and not in others, right?

[Dr Rena Kasick]
Yes, exactly. For sure. Some are better at expectation settings and having that clear communication, which are essential.

[Dr Mike Patrick]
Yeah, yeah. So that would be one challenge. Karen, what other challenges do residents face as they transition from complete supervision to autonomy?

[Dr Karen Allen]
Yeah, we asked that same question to our residents in our study, as well as the residents at the other institutions at our study. And overwhelmingly, they did say working with their attending, like you mentioned, it's really attending dependent on who's going to be able to grant them autonomy and who feels comfortable granting them autonomy. But they also mentioned a couple other things.

One of the big things is, is there a fellow on service? And what is the level of autonomy granted to that fellow or other learners on service? So, if there are a lot of learners on service, potentially a fellow, senior resident, several interns, medical students, sub-Is, that can kind of create a crowding effect in which there's maybe not as much opportunity for a single resident to exercise as much autonomy.

Our culture of pediatric medicine has been great and really focusing, especially on the inpatient side of things, on patient safety. And with that has come some increased attending supervision, decreased duty hours, which are great for our patient safety, but then can limit the number of opportunities residents have to practice autonomously on the wards. And then families and nursing staff may have this expectation that as the attending physician, you're going to be involved in every decision.

So, they may be looking to you as the attending physician rather than going through the resident first to have that opportunity to think critically and act autonomously. So, there are a couple of things that may provide a challenge to residents getting autonomy, but definitely there are also ways for us to promote those opportunities where we can.

[Dr Mike Patrick]
Yeah. Yeah. And so, like as an attending, if a nurse contacts me with a question and I say, hey, call the resident, I'm not necessarily being lazy and not wanting to answer, but I'm really trying to provide that resident with an opportunity to think critically and come up with a, an answer on their own.

Now they may circle around and, and say, come to the attending and say, hey, is this the right thing? I'm not quite sure. And of course, we would encourage that because that's part of, you know, knowing what your own limitations are and what you do know and knowing what you don't know and how to find the answer to the things you don't know.

You know, it's all part of that autonomy journey for sure. We talk about feedback being an important thing. So of course, you know, sitting down and getting to know your resident ahead of, you know, at the very beginning of a rotation, but feedback during a rotation is really important too.

Karen, can you explain its role in the development of resident autonomy?

[Dr Karen Allen]
Yes. I, I like to think of feedback and entrustment as very closely related. So, residents are not going to know where their deficits are or where their strengths are unless there's a third-party observer, like a faculty member really taking in and observing them and telling them how they can improve.

So, in order for residents to improve and become independent doctors that we hope they are at the end of their training, they're going to need expert opinion and feedback to tell them, hey, this is what you're doing correct. And this is what you can improve on. And definitely, I think as attendings, we need to see that residents are able to respond to that feedback in order to feel comfortable entrusting them with more autonomy.

[Dr Mike Patrick]
Yeah. And I think that's sometimes difficult for many attendings because we want to be supportive. We want to, you know, feel like we're helping, and we are, but when we provide critical feedback, sometimes that can feel like we're criticizing and that may not feel so good.

Do you have any advice for attendings on how they can best provide critical feedback in a positive way?

[Dr Karen Allen]
Yeah, that's great. I think it's our best idea is to make sure we're not making this personal as far as you did this wrong, you should do this better and more just talking about opportunities and having direct examples to lead to. So, saying, hey, I saw that this happened.

I think that it would be better to do it this way. And that may help the resident take it in rather than these more directed you statements. Rina has definitely, as an ATD, dealt with a lot of feedback for our residents.

So, she may have more things to say about how to improve our feedback to people that may be resistant to getting feedback.

[Dr Rena Kasick]
Yeah, I think it's grounded in creating this environment for psychological safety. So, when learners feel that they are safe and, you know, able to make mistakes and learn from them, I think that feedback naturally happens a lot better. So, that's one point that I wanted to highlight for sure.

[Dr Mike Patrick]
Yeah. And then what other strategies, Rina, are important in terms of, you know, balancing the supervision with the autonomy? You know, one is the feedback, as we mentioned, but what other strategies can kind of promote that journey?

[Dr Rena Kasick]
Yeah. So, I think when feedback is effective, it's often grounded in a shared mental model of what things should look like, you know, on rounds and, you know, we're hospitalists. So, that's the example that we kind of go to.

But, you know, essentially, what does autonomy mean to the resident and the attending? So, an understanding of the resident's fund of knowledge, their clinical reasoning skills and expectations on how to communicate, and how the attending expects all that to happen needs to be discussed early in their working relationship. And again, as Karen mentioned, and as you mentioned also, Dr. Mike, it requires bi-directional feedback frequently, oftentimes a degree of self-reflection on the attending's part and how they supervise their trainees. I think especially at the beginning of the academic year, or I should say towards the end of the academic year, the interns are ready to manage patients with bread-and-butter pediatric complaints such as bronchiolitis and dehydration. So, how can we as teaching faculty just take a step back, validate and support their medical decision-making, and allow their plans to be enacted?

[Dr Mike Patrick]
Yeah, you know, when I work with residents and working in the emergency department, I not only work with pediatric residents, but emergency medicine residents from adult programs and family practice residents. And, you know, because so many things, there are a lot of things in medicine that's cut and dry. This is what you need to do.

This is the standard of care. And then there's also a large gray area where some folks do it differently than others, and it may be different from one institution to another. You know, do you do your steroids twice a day or do you do them once a day, just as an example?

And so, I think that allowing that autonomy, but the caveat being, please explain to me why you're doing what you're doing. So it may be different than the way that I do it, but if you can give me a good reason that makes sense and is based on evidence, then I'm going to be a lot more likely to let you do that because, you know, not everything has to be done exactly the same way, although there are some things that do. And part of our journey to autonomy is learning which of those things there is wiggle room and preferences and which ones are standard of care.

And this is what we need to do, at least as of right now with the data that we have. As we're talking about all of this, high quality patient care is, you know, extraordinarily important. So how do we ensure that we are providing high quality patient care as residents make that transition from supervised to autonomy?

[Dr Rena Kasick]
Yeah, I think for one, it's the responsibility of the resident and the attending to have an open dialogue, as we've mentioned before, and set expectations. And I feel like we say this a lot, but truly I think that's the crux of a lot of these working relationships and successful ones have a successful way of communicating. So, the residents must be willing to demonstrate what they fully do and then also do not know.

So be vulnerable and talk to their mentors and faculty on what they need guidance on and be willing to adjust their clinical reasoning and plans. And as you've mentioned before, you know, if there's really no true evidence-based guidance on XYZ decisions, but the resident provides a really good rationale for why they think they should pursue this plan, I think the attending should really kind of perform, think about how to do this a little bit better and allow that plan to be enacted.

[Dr Mike Patrick]
Yeah, yeah. And I think as attendings, if you think about even your own practice partners, you likely do things a little differently than some other people do, and you have good reasoning for why you do it that way. And, you know, being able to explain that as an attending to patients, to staff, you know, nurses may ask, wait, other people do it this way.

Why are you doing it that way? So, I think part of that is just being an educator, not only with residents, but also with nurses and staff and with patients to explain why we do the things that we do. And hopefully we have good rationale for why we do it that way.

And the resident may say, oh, that's a really good point. And maybe I'll start doing it your way. And, you know, I may say to the resident, you know, that's actually a really good idea.

And that does happen. I mean, we really do learn from each other. And sometimes I feel like the residents, you know, because they see how one attending does it, and then they suggest it to you, and you may pick that up, or you may explain why you don't like to do it that way.

And so, I mean, we're all learning as kind of in a big network, so to speak. And I imagine that that's pretty good for high-quality care because you've got, you know, multiple brains thinking about things from different perspectives. I know we're going to have a lot of resources in the show notes over at pediacast.org.

This is episode 106. And the paper that you guys wrote, the Autonomy Toolbox, a multi-center collaborative to promote resident autonomy. Tell us, Rena, a little bit more about your paper.

[Dr Rena Kasick]
Yeah, so I'll have to backtrack a little bit because this work was really kind of inspired by others who dived into how we can improve resident autonomy in pediatric residency training. So, Stanford actually studied independent rounds on inpatient general pediatric wards where they allowed the senior resident to see patients on their own, along with the interns and the medical students. And the supervising attending was actually close behind seeing patients afterwards.

And a few themes emerged from this study. Residents felt increased motivation to take full ownership of their patients and teaching on rounds, which was really cool to see. And then there's this unique self-driven learning that happened, and they were able to incorporate EBM consistently on rounds, which is amazing.

And importantly, as we've highlighted before, there were no patient adverse events. Faculty did express some concerns about the ability to provide feedback and evaluate their teams, as we've mentioned. And then all groups actually cited that communication concerns were the biggest thing when they saw patients asynchronously.

Some plans did change after the attending saw the patients. So, while we were quite interested in resident-led independent rounds and what that could look like at Nationwide Children's, we quickly realized that we had to lay more foundation in our work. So, Dr. Karen Allen was the first author of our manuscript, again published in Hospital Pediatrics in 2023, 2024 actually, which highlighted our multi-institute collaborative that was aimed to improve resident autonomy experiences or opportunities in training. We collaborated with some great medical educators, so from Children's Wisconsin and Milwaukee, Cincinnati Children's, CHOP, and Johns Hopkins, and we studied three things. We looked at providing resident faculty more information and faculty development on how we could do this better using a framework called SHREA-21 or the Senior Resident Empowerment Actions, which described behaviors for both resident attendings to empower senior residents to step up and lead rounds and medical decision-making on rounds. Secondly, we also provided a framework for expectation setting.

And then our third intervention was the implementation of senior resident-led independent rounds. And when we bundled that all together, those three interventions, we saw an improvement in resident autonomy opportunities by nearly 20 percent, which was awesome.

[Dr Mike Patrick]
Now, when you say resident independent rounds, is the attending, you said they follow behind, or are they there for those rounds, or are they, then do they just get a report back after the rounds have been completed?

[Dr Rena Kasick]
Yeah, we provided some flexibility because certain attendings did not want to be too far away from rounds and, you know, where the action was, so some attendings, you know, allowed independent rounds to happen on a certain number of patients on their list, and others allowed that opportunity a little bit more fully. And it didn't happen all the time, so we challenged our attendings to really consider at least one day a week, usually typically at the end of the week, to consider independent rounds, which was a great learning experience for both residents and faculty.

[Dr Mike Patrick]
Yeah, I was going to ask what the feedback has been from the residents' perspective on doing that. I imagine there'd be, especially for some younger residents, there might be some trepidation in the beginning, but then as they get more comfortable doing things independently, it might get easier and then even satisfying.

[Dr Rena Kasick]
Yeah, I'll have to maybe briefly, like, summarize the feedback now that I think about it is, so yeah, you're exactly right. The early second-year residents were a little bit more hesitant to jump into that role. I think the third years and the fourth-year MedPeds residents embraced it a little bit more completely, but it was just a great learning opportunity.

Our nurses were on board. Our medical students really liked to have that teaching happen directly from their senior residents. So, we were beginning to create this culture and this environment where active learning was happening, and people were really embracing their roles.

[Dr Mike Patrick]
Yeah, and we'll put a link in the show notes to that article, the Autonomy Toolbox. And again, Karen was the lead author and Rena the senior author of that, and it was published in the journal Pediatrics, so folks can find that easily. Oh no, it was actually published in Hospital Pediatrics, right?

That's a different journal. Okay, and then there's also a nice commentary on the Autonomy Toolbox, also in Hospital Pediatrics, called Autonomy is Desired, Entrustment is What Matters, and we'll put a link to that. That was an interesting commentary.

I will put that in the show notes as well. And then we do have some residency programs that do the journey to autonomy really well, that I know you guys had suggested some really good ones. One is the coaching program that you had mentioned at Stanford, their pediatric residency.

We also have one at Columbia University in New York City, and another at Ochsner Hospital for Children in New Orleans. So, we're going to have a lot of resources in the show notes if you're interested in what other programs are doing, and the Autonomy Toolbox that Rena and Karen wrote about, we'll have links to all of those things in the show notes. Karen, I want to circle back to you.

What impact then does resident autonomy have on patient outcomes? So, you know, we've said how can we keep things safe, but can we actually improve outcomes by putting a focus or a spotlight on resident autonomy?

[Dr Karen Allen]
Yeah, a lot of the published work on this is more indirect. So, Rena mentioned the paper out of Stanford in which the independent rounding did not lead to worse outcomes. And then there's another paper by Fenn et al.

from 2018 that talks about how medical errors are affected by increasing attending supervision. And they found that increasing attending supervision did not lead to less medical errors. So again, that's kind of an indirect measure saying that more resident autonomy doesn't necessarily equate to poor patient outcomes.

We know that increased resident autonomy, like Rena mentioned earlier, can really increase resident sense of patient ownership and motivation to take more effective care of patients. So again, that's again a little bit more indirect. In our paper, one of the balancing measures that we looked at was patient and family satisfaction to say, was there any change in the level of satisfaction that we were seeing as residents took on more autonomy and started taking more direct leadership role in rounds?

And we found that it did not. It was overwhelmingly high, higher than most other published literature at baseline, and it remained at that high level even after we enacted these interventions to try and really center our senior residents as leaders of the team. So overall, again, we can't say one way or another that autonomy, because it's again more of a spectrum, less discreet, leads to better or worse outcomes, but all signs point to no worse outcomes and potentially better, more effective care of patients.

[Dr Mike Patrick]
Yeah, yeah, that really does make sense. And I would suspect that if you did design a study, you know, to sort of show that's true, you probably would be successful at that. But again, that's just anecdotal evidence based on our own experiences, but definitely something that's worthwhile looking into to make sure that we are improving, hopefully not even just not having worse outcomes, but maybe even improving outcomes as we all support each other and communicate.

And part of allowing autonomy is kind of checking after the fact to make sure that we're doing things correctly. And if we're not doing them the way that I want them done, you know, understanding why that is, and maybe that ends up being a better way. And so, you know, we do improve outcomes by all talking about things together and giving residents, you know, the opportunity to practice autonomously.

You know, we talked about the resident independent rounds. What are some other autonomy initiatives in pediatric training programs that have been successful, Rena?

[Dr Rena Kasick]
Yeah, the one in particular, which we really adapted from was from Children's Hospital in Milwaukee and looking at the Street 21 tool and other programs specifically in New York also looked to use this tool to kind of assess and determine, you know, how are faculty doing at providing these opportunities? And how are residents doing in stepping up into these roles? So that's one that comes to mind that we heavily adapted to use in our study as well.

[Dr Mike Patrick]
Yeah. And what about in resident-led clinics? So, I know you are both hospital medicine folks.

And so, you know, you can have the independent rounds. What about in like primary care clinics where residents are learning? What does a good autonomy initiative look like in that environment?

[Dr Rena Kasick]
Yeah, I think that's a great question and something that we have not looked into directly. But when I think about how that that clinic model is run for our residents, there are a lot of clinical decision making that that is happening for each and every patient. And sometimes the residents may feel that those decisions are passive decisions.

It's just on autopilot. But in reality, you know, every single question that they entertain from patients and parents is an opportunity to provide some anticipatory guidance, next steps and return precautions. So that in itself is an opportunity for residents to really engage in providing parental guidance.

But it's, in a sense, practicing autonomously.

[Dr Mike Patrick]
And yeah, and it's so important not to forget about the primary care folks and how autonomy can be achieved in that realm, especially for residents who may be going into primary care. And this is really what they're going to be, you know, doing during their career. And then there's also the teaching aspect of autonomy, because there are residents who are going to have a career in academic medicine and are going to become teachers.

And so, do we also think about a journey toward autonomy in terms of teaching, like residents teaching each other or residents teaching medical students that, you know, may be on service with them? Is that something that's also looked at?

[Dr Rena Kasick]
Yes, and I'm glad you highlighted that because we in our residency program have teachers as a resident as teachers initiative. Spans across the three years of pediatric training with us. Within it are didactics and essentially resident development sessions to hone in on teaching skills.

And then the opportunity kind of comes about as they become senior residents in their second and third year. They teach on inpatient rounds. They teach in the clinic and provide guidance or interns who are new to that setting.

So, we're really mindful and thoughtful about how, what that could look like and try our best to help them hone their teaching skills.

[Dr Mike Patrick]
Yeah. And Karen, what do residents think about all this? As we think about this concept of autonomy, is this something that they perceive as an important journey?

[Dr Karen Allen]
Yes. So, kind of as we alluded to, our residents are not monolith. So, they definitely are also on their own spectrum of where they are as far as readiness for autonomy and the importance of autonomy to them.

Regardless of their personal opinion, they are going to need to be able to practice autonomously at the end of their training. So, we need to make sure that we're setting them up with the tools to do so. They, in the survey data that we have from them from during our study, they kind of cited some of the similar barriers as things they would hope to overcome in order to be more autonomous.

So, the fact that there's lots of learners on service, the fact that the attending might always be like present and nearby, and so that you don't have that chance to really think critically about problems without turning to your attending and saying, hey, what do you think about this? Just like how busy inpatient service is. Those are all sort of things that they mentioned as like potential barriers.

And we sort of designed our interventions in this autonomy toolbox paper to kind of address those barriers and go with the suggestions that they asked for. So, a lot of the things that the residents were hoping that we would address with this quality improvement initiative was that they didn't always know what their expectations were from their attendings. They wanted the chance to maybe round independently.

And they just wanted to know what they can do to sort of be the leaders of the team. So that's kind of how we focused our interventions was based off of what they said that they thought would be helpful. So, for example, in our intervention here at Nationwide, we sort of came up with a contract between an attending and a resident to say, these are the sort of decisions that I think that the resident should make.

And these are the sort of things that I think the attending needs to check in. And so that kind of set a more formalized setting for our residents so that they at least know what they can expect throughout their service week. As Rena mentioned, we instituted our independent rounding at least one day a week.

We thought maybe our residents and our faculty could handle at least one day a week of that. And then we really tried to hit hard with these senior resident empowerment action tools, SREA 21 that Rena mentioned, by both doing our development sessions, but also we gave our residents and our faculty little badge buddies that like when attached to their badge so people can reference it and know that it's an important thing that residents and faculty should be valuing to try and promote while they're on rounds.

[Dr Mike Patrick]
Yeah, great ideas. When institutions are really trying to get their residents to become more autonomous, so from the residency training programs perspective, this is something that's going to be really important for you. The focus of the institution itself may be a little bit different.

What challenges are there in terms of institutional level barriers to that transition to resident autonomy, Rena?

[Dr Rena Kasick]
Yeah, so while I think some clinical areas and particular teaching faculty were great champions for resident autonomy, the biggest barrier honestly was a little bit more nebulous. It was kind of the culture of the hospital and training environment in general and in pediatrics, I think across the board, not only at our institution. Faculty are just more used to prescribing the next steps for their patients a bit more because we're taking care of children, right?

So, it doesn't often allow a lot of room for the trainees to kind of insert themselves and develop their medical decision-making. So along with resident feedback in various forms and through our collaborative project, we've really worked to open the dialogue on resident autonomy and improve the training environment for the better, and this happened across all five sites. So, we're hopefully dismantling some of that as we continue this work.

[Dr Mike Patrick]
And from the institution's point of view, what can they do specifically to support this process?

[Dr Rena Kasick]
Yeah, so the answer is complex, and the solution therefore is probably multifactorial. So, for those of us in teaching hospitals thinking about how we prime our learners, providing orientation to a clinical environment and setting those expectations can go a really long way. Collaborating with nursing and other inadvertent teachers can really help them be allies in educating our resident learners.

At our institution, we also have several evidence-based clinical pathways that can be leveraged, which can help, I think, also promote resident autonomy. I think the thing that we have to be cautious of as educators is that we have to ensure that the residents understand the why of what we're doing, right, instead of just following an algorithm. So, as you mentioned before, explaining our rationale or having the resident explain their rationale before a plan is put forth.

[Dr Mike Patrick]
Yeah, yeah, really, really important things. And I love that you mentioned that interprofessional collaboration, and in particular, this podcast, we do have joint accreditation, so we not only have physicians listening, but we also have nurses and pharmacists and dentists and social workers. So, Karen, what is the role, then, of other professionals who collaborate with attendings and residents?

How can they help residents grow in their journey toward autonomy?

[Dr Karen Allen]
Yes, it's very important that we have the full team's buy-in for resident autonomy. And I think, in particular, our nursing staff and our residents are in almost constant contact throughout the day, making a lot of micro decisions and putting in orders for patients and making sure that direct patient care happens. So, it's really important for our residents that the nursing staff is on board and supportive of their resident autonomy journey.

And I think as we try and improve it across the institution, our nursing partners are going to be very instrumental in making sure that our residents are there. And I think it is really a two-way street, and a lot of that happens across the time as nurses and residents learn to entrust each other and value each other. I think that that's only going to create a positive learning environment and probably improve patient outcomes.

[Dr Mike Patrick]
And I would say that the nursing staff is really a huge one. Another important one, I feel like, are the clinical pharmacists. Like, more and more, they are really an active part of teams, and they have a lot that we can learn from.

And so, you know, I always encourage, you know, residents in the emergency room, when we have a question related to pharmacologic agents, like, oh, let's ask our friendly neighborhood clinical pharmacist. And they are always really happy to teach. Do you find that in hospital medicine?

Are the clinical pharmacists also helpful in your space?

[Dr Karen Allen]
Oh, definitely. And we are very lucky in that most of our teams are able to round with the clinical pharmacists on rounds. And then they are also very easily accessible via EpicChat or via Vocera.

So, really easy for our residents to learn from our pharmacists, as well as help them, support them to make these decisions either on rounds or after rounds.

[Dr Mike Patrick]
And then, Karen, what about technology? So, you know, as we think about heading toward autonomy, are there simulations or, you know, I think about pilot training and, we have flight simulators so that we can become more autonomous, but definitely in a safe manner. Does technology and innovation play a role in the journey to autonomy for residents?

[Dr Karen Allen]
You know, I have not thought about simulations as a possibility, but I think that's a great idea, especially here at Nationwide. We have that excellent simulation center and simulation team. When I think of like technology and how it's advancing, I think of our EMR and particularly at our institution, we use the SecureChat function.

And I think it has both promoted and somewhat jeopardized our resident autonomy. On one hand, I feel like our residents are very accessible and therefore like our nursing staff feels free to reach out and ask questions to them very easily. And they can respond quickly and kind of make those decisions together, which in turn leads to increased rapport, increased entrustment, and probably increased autonomy.

But unfortunately, us as faculty are also very accessible via Epic Chat. So, I think it's very easy for residents to defer to us by adding us to our SecureChat or reaching out to us. And they may have previously just addressed a concern or thought critically about a concern without getting us involved in all of these like micro decisions.

I also think that one of the big things that residents time and time again voice some concern is if they're circumvented in these decisions. So, if someone comes to an attending without first going to a resident to ask a patient care decision, they are very frustrated by that. And again, it does undermine some autonomy that they have.

So, that's one way I think technology may jeopardize it in that because we are so accessible as attendings, people may circumvent the resident to talk to the attending. And we as faculty need to do our best to try and bring the resident back in on these discussions and try and step out until we're absolutely needed so that our residents have the opportunity to really think critically about any sort of patient care question.

[Dr Mike Patrick]
Yeah, that's a really good point. And, you know, as I think back before the pandemic, we weren't really using SecureChat very often, except for, you know, like a little one-off message here and there. But since the pandemic, I feel like as folks have become more comfortable, I think during the pandemic, in terms of like Zoom meetings and just, you know, virtual meetings and connections, that SecureChat is really being used a lot more and it is so convenient.

But it's a great point because, you know, how many times do I get a message from a nurse and they only put me as the attending on the message? And really, I ought to be looping in the resident, you know, adding them to that SecureChat and then maybe even just saying, hey, I'll let so-and-so answer or just, you know, if they were in there originally, just let them answer and just kind of hang and sure, you can watch. And, you know, if you're seeing something you don't like, you can talk to the resident but at least giving them the opportunity to respond.

Because you're right, a lot of that autonomy occurred. Like, as I think back to when I was a resident, you know, you got all those calls from the nurses and you had to make decisions and you had to determine, like, which decisions am I fine making on my own and when do I need to loop the attending in? And that is all a part of that autonomy journey.

So, I just, I'll put a plug out for folks who use SecureChat a lot, you know, really do think about whether that is helping or harming our residents in terms of their growth and heading toward autonomy. So, good, good. And then, of course, the simulation stuff, there's just so much, you know, that can be done these days from a technology standpoint and with AI and who knows what five years from now that's going to look like in terms of what can be done in a sim kind of fashion.

Rena, I wanted to close up with just a focus on our pediatric residency training program here at Nationwide Children's Hospital. Tell us how autonomy is being implemented at this institution and why medical students who are interested in pediatrics ought to really consider training here in Columbus.

[Dr Rena Kasick]
Yeah, so I think we're lucky at Nationwide Children's to have faculty educators who are really invested in the training of our residents and developing best practices to promote resident autonomy. Our residents get to see a lot of bread-and-butter cases, and I think being a tertiary and quaternary center, we get to see a lot of rare zebra cases too, which in itself is a lot of learning. So, there's a lot of learning from each and every patient encounter.

Things that we're doing at Nationwide Children's is continue to work on faculty development across, you know, general pediatrics and certainly, but also our subspecialists and having faculty really consider how they can best encourage resident autonomy and continue to work with our residents to empower them a little bit more and helping them step into that role a little bit more so that we can optimize those learning opportunities.

[Dr Mike Patrick]
Yeah, it's really a great program. I trained here. Things were a little different back 30 years ago, but it has continued to be really a premier residency training program, whether you're going to go into general pediatrics or pursue a subspecialty field after your residency, it's really a great place to be.

And I'll put a link to the pediatric residency training program at Nationwide Children's in the show notes over at pdacastcme.org. Once again, episode 106. So again, Dr. Rina Kasich and Dr. Karen Allen, both with hospital pediatrics and Rina, an associate program director with our residency program. Thank you both so much for being here today.

[Dr Rena Kasick]
Thank you so much. 

[Dr Karen Allen]
Yeah, thanks for having us.

[Dr Mike Patrick]
We are back with just enough time to say thanks once again, to all of you for taking time out of your day and making PediaCast CME a part of it. Really do appreciate that. Also, thanks again to our guests this week, Dr. Rina Kasich and Dr. Karen Allen, both with pediatric hospital medicine at Nationwide Children's Hospital. Don't forget, you can find us wherever podcasts are found. We're in the Apple podcast app, Spotify, iHeartRadio, Amazon Music, Audible, YouTube, and most other podcast apps for iOS and Android. Our landing site is pdacastcme.org.

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Now be sure to claim your free Category 1 Continuing Medical Education credit. Really easy to do. Just head over to the show notes for this episode at pdacastcme.org.

You'll find a link to the post-test in the show notes. Follow that link to Cloud CME, click on the materials tab, take and pass the post-test and the Category 1 credit is yours. Super easy.

And again, we offer credit to many pediatric professionals, including doctors, nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists. Of course, you want to be sure the content of this episode matches your scope of practice. Complete details are available at pdacastcme.org.

Also, don't forget about our pediatric podcast for parents called PediaCast. It is also evidence-based and actually lots of pediatricians and other medical providers tune in as we cover pediatric news and interview pediatric and parenting experts. Shows are available at the landing site for that program, PediaCast.org.

Also available wherever podcasts are found. Simply search for PediaCast. And an additional podcast that I host, we just launched it last month.

It's called FAMEcast, and that is a faculty development podcast from the Center for Faculty Advancement, Mentoring, and Engagement at The Ohio State University College of Medicine. So, if you're a teacher in academic medicine or a faculty member in any of the health sciences, then this is a podcast for you. You can find FAMEcast at famecast.org and wherever podcasts are found, just search for FAMEcast, F-A-M-E-C-A-S-T. Thanks again for stopping by and until next time, this is Dr. Mike saying, stay informed, keep it evidence-based, and take care of those kids. So long, everybody.