Cello

Oversight, ownership, and the 

development of expertise

Part 5: When the best laid plans get waylaid

So, you've done everything right by setting expectations to maximize ownership and oversight with your learners and team at the beginning of your shift, but you've had five new patients, including 1 destined for the ICU, in the past 50 minutes. What now?

Divide and conquer or stay the course? There is no right answer to this question, but there are multiple important considerations:

Residents need practice making triage decisions, so if they are at an appropriate phase in their training, consider allowing them to prioritize and care for patients based on illness severity. This is an important component of their training that also requires feedback and deliberate practice. Consider setting a limit on the number of waiting patients or duration of wait.   

Be patient-centered. It is neither helpful for the learner nor safe or satisfying to patients for the resident to be so totally overwhelmed with clinical work that multiple patients are waiting to be seen. In these cases, we recommend using the additional resource provided by the attending to meet this demand. In this "divide and conquer" scenario, you will need to address how oversight will occur so the learner can still receive appropriate feedback. In cases of simultaneous patient arrivals, ask residents whether they prefer to take ownership from you after the initial evaluation. If the resident is already over-taxed, we recommend the supervising physician manage the patient independently. As educators, we want to optimize the challenge to be difficult but achievable and safe. 

You should work with the learner at the beginning of the shift to develop a plan for how ownership and oversight will change when things get busy. Deciding up front how to handle this issue will help you rise to the challenge in the heat of the moment.

Eyes on the Prize:
As you employ strategies that optimize ownership and oversight, remember that the goal of deliberate supervision is to drive deliberate practice among trainees. Don't forget to continue asking probing questions and provide feedback that helps learners refine their future practice.

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Resources

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.