Overextending: A Qualitative Study of Trainees Learning at the Edge of Evolving Expertise.

BACKGROUND

The challenge of graduate medical education is to prepare physicians for unsupervised practice while ensuring patient safety. Current approaches may inadequately prepare physicians due to limited opportunities for autonomy. Recent work on how trainees gain autonomy shows that they actively influence their supervisors' entrustment decisions. If program directors more clearly understand how trainees experience increasing independence, they may better sensitize trainees to the deliberations they will face during patient care.

OBJECTIVE

The authors sought to explore how trainees experience lessening supervision as their clinical training advances.

METHODS

Using constructivist grounded theory, the authors recruited trainees from various specialties and training levels via email and conducted 17 semi-structured interviews from 2019 to 2020 to solicit clinical experiences during which their perceived autonomy changed. Through constant comparison and iterative analysis, key themes and conceptual relationships were identified.

RESULTS

Seventeen trainees from 4 specialties described novel clinical situations that required "overextending," or going beyond their perceived edge of evolving expertise. This move represented a spectrum based on perceived locus of control, from driven by trainees, to driven by external factors. Trainee judgments about whether or not to overextend were distilled into key questions: (1) I do it? (2) I do it? (3) Do I to do it? and (4) Is it to do it? More advanced trainees posed a fifth question: (5)

CONCLUSIONS

Decisions to move into the realm of uncertainty about capabilities carried weight for trainees. In making deliberative judgments about overextending, they attempted to balance training needs, capability, urgency, and patient safety.