Goldszmidt Mark, Faden Lisa, Dornan Tim, van Merriënboer Jeroen, Bordage Georges, Lingard Lorelei
M. Goldszmidt is associate professor, Department of Medicine, Division of Internal Medicine, and associate director, Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada. L. Faden is research specialist and education coordinator, Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada. T. Dornan is professor of medical education, Department of Educational Development and Research, School of Health Professions Education, Maastricht University, Maastricht, the Netherlands. J. van Merriënboer is professor of learning and instruction and research program director, Department of Educational Development and Research, School of Health Professions Education, Maastricht University, Maastricht, the Netherlands. G. Bordage is professor, Department of Medical Education, College of Medicine, University of Illinois at Chicago, Chicago, Illinois. L. Lingard is professor of medicine and director, Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada.
Acad Med. 2015 Nov;90(11):1541-6. doi: 10.1097/ACM.0000000000000735.
There is wide variability in how attending physician roles on teaching teams, including patient care and trainee learning, are enacted. This study sought to better understand variability by considering how different attendings configured and rationalized direct patient care, trainee oversight, and teaching activities.
Constructivist grounded theory guided iterative data collection and analyses. Data were interviews with 24 attending physicians from two academic centers in Ontario, Canada, in 2012. During interviews, participants heard a hypothetical presentation and reflected on it as though it were presented to their team during a typical admission case review.
Four supervisory styles were identified: direct care, empowerment, mixed practice, and minimalist. Driven by concerns for patient safety, direct care involves delegating minimal patient care responsibility to trainees. Focused on supporting trainees' progressive independence, empowerment uses teaching and oversight strategies to ensure quality of care. In mixed practice, patient care is privileged over teaching and is adjusted on the basis of trainee competence and contextual features such as patient volume. Minimalist style involves a high degree of trust in senior residents, delegating most patient care, and teaching to them. Attendings rarely discussed their styles with the team.
The model adds to the literature on variability in supervisory practice, showing that the four styles reflect different ways of responding to tensions in the role and context. This model could be refined through observational research exploring the impact of context on style development and enactment. Making supervisory styles explicit could support improvement of team competence.
教学团队中主治医生角色的履行方式，包括患者护理和实习生培养，存在很大差异。本研究旨在通过考虑不同主治医生如何安排和合理化直接的患者护理、实习生监督及教学活动，更好地理解这种差异。
建构主义扎根理论指导迭代式数据收集与分析。数据来源于2012年对加拿大安大略省两个学术中心的24位主治医生进行的访谈。在访谈过程中，参与者听取了一个假设性陈述，并像在典型的入院病例讨论中向他们的团队展示一样对此进行思考。
确定了四种监督风格：直接护理型、赋权型、混合实践型和极简主义型。出于对患者安全的担忧，直接护理型将最少的患者护理责任委派给实习生。赋权型专注于支持实习生逐渐独立，运用教学和监督策略确保护理质量。在混合实践型中，患者护理优先于教学，并根据实习生能力和诸如患者数量等情境特征进行调整。极简主义型对高年资住院医生高度信任，将大多数患者护理和教学工作委派给他们。主治医生很少与团队讨论他们的风格。
该模型丰富了关于监督实践差异的文献，表明这四种风格反映了应对角色和情境中紧张关系的不同方式。该模型可通过观察性研究加以完善，探索情境对风格形成和履行的影响。明确监督风格有助于提高团队能力。
