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Oversight, ownership, and the development of expertise

Part 3: Scaffolding for optimized ownership

Team-based care seems like a great goal, but what do you do when your learner isn't ready for ownership? 

The issue of ownership is really all about trust. How much do you trust the resident to manage patients? the zone? the ED? The reality is that the ideal amount of ownership is relative, multifactorial, and learner-dependent. 

Keep in mind that learners and supervisors tend to assess ownership differently; supervisors almost always perceive higher levels of ownership by learners than the learners themselves perceive. For this reason, it's important to address early in a shift what expectations you and your learner have about ownership. You should, at a minimum, discuss: 

  • what aspects of care and decision making the learner will be responsible for, and for whom.

  • when you would like to be involved by the learner (encourage self-disclosure of discomfort with decision making, procedural skills, and task-saturation).

  • the circumstances under which you will dial back their ownership (consider timing, safety, failure to meet expectations, etc). This should not be seen as punitive, but rather a titration to an appropriate level of ownership.


Aim for a level of ownership that pushes the learner and helps him or her improve, not necessarily "complete ownership," which is more likely than not setting up a junior resident for failure. This process is known as scaffolding; you help the resident advance to increasing levels of ownership by identifying and then pushing them towards the next step in their development. 

Even if your tendency is to let residents fully manage their patients (i.e. you default preference is for a high-ownership state), it is important to recognize the importance of expectation setting around issues of ownership, since it can be easy to unknowingly slip into the unsupervised autonomous state. This is especially true with high-achieving learners who may be reluctant to self-disclose when they are uncomfortable. 

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Biondi EA, Varade WS, Garfunkel LC, et al. Discordance Between Resident and Faculty Perceptions of Resident Autonomy. Academic Medicine 2015;90(4):462–71.

Ericsson KA. (2016). Peak: Secrets from the New Science of Expertise. Boston : Houghton Mifflin Harcourt.

Ericsson KA. (2004). Deliberate Practice and the Acquisition and Maintenance of Expert Performance in Medicine and Related Domains. Academic Medicine, 79(10), S70–S81.

Ericsson KA, Krampe RT,  Tesch-Römer, C. (1993). The role of deliberate practice in the acquisition of expert performance. Psychological Review, 100(3), 363–406.

Ericsson, KA. (2009). Development of professional expertise: toward measurement of expert performance and design of optimal learning environments. New York, Cambridge University Press. 

Gladwell, M. (2008). Outliers: The story of success.

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